Standing Committee E

[Mr. John Maxton in the Chair]

Health and Social Care Bill

John Denham: I beg to move,
 That the Programming Order of the Committee of 18th January be amended—
 (1) in paragraph (1), at the end, by inserting the words `(save on the afternoon of Thursday 25th January, when the Committee may sit until Seven o'clock)'; and
 (2) in the Table, by leaving out the entry in the third column in respect of the 5th sitting and inserting instead '7 p.m.'
 The resolution does not deal with a possible sitting on Monday afternoon, but if we do not make sufficient progress this afternoon we might need to convene the Programming Sub-Committee later. 
 Question put and agreed to.

Clause 22 - Unsuitability for inclusion in medical, dental,ophthalmic and pharmaceutical etc. lists

John Denham: I beg to move amendment No. 116, in page 15, line 6, at end insert—
 `( ) In section 29A (medical lists), after subsection (4) there shall be inserted—
``(4A) Regulations may make provision in relation to the supply to a Health Authority, by a medical practitioner who is included in their medical list (or, as respects paragraph (a), by arrangement with him) of—(a) information of a prescribed description; and
(b) a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act.'''.

John Maxton: With this we may discuss the following: Government amendments Nos. 117 to 120.
 Amendment No. 170, in page 15, leave out lines 29 and 30. 
 Government amendment No. 121. 
 Amendment No. 171, in page 16, leave out lines 1 and 2. 
 Government amendment No. 122. 
 Amendment No. 172, in page 16, leave out lines 16 and 17. 
 Government amendments Nos. 123 to 126. 
 Amendment No. 173, in page 16, line 29, leave out from `inclusion' to end of line 31. 
 Amendment No. 174 page 16, line 35, at end add— 
 `(7) In sections 29B, 36, 39, 42 and 43 the expression ``grounds of unsuitability'' shall mean, in relation to such person, grounds that enable the Health Authority (or on appeal the FHSAA) to be satisfied that it is— 
 (a) necessary in the public interest or for the protection of members of the public; or 
 (b) in the interest of the person concerned 
 that such person is not included in the respective list and, elsewhere in this Act the word ``unsuitability'' shall be construed accordingly.'.
 Government amendments Nos. 127 to 133.

John Denham: This is a lengthy group of amendments, so before speaking to the clause in general terms, I shall discuss the amendments themselves.
 Clause 22 forms a key part of our package of measures to improve the quality of delivery of primary care services—a subject on which I touched in our discussions on Clause 19. Clauses 25 and 27 also deal with lists, and taken together clauses 22, 25 and 27 cover doctors, dentists, pharmacists and optometrists. They cover non-principals as well as principals, and practitioners under part I or part II of the National Health Service Act 1977. Between them, the clauses apply the same principles and procedures to each list, and any variations are those required by the circumstances of the particular group. Clause 22 deals with part II principals by amending the existing powers. 
 Clause 22 will also deliver more consistency to the provisions applying to each practitioner group. That is important, because although each practitioner group has distinct and different roles, in each case potential risks to patient safety can arise through the possibility of inappropriate or unscrupulous behaviour by a practitioner who is unsuitable for the role. 
 It might come as a surprise to some to learn that health authorities do not already have such powers. They have the power to refuse admission in some circumstances, but it has become clear that the powers are currently drawn too narrowly to be applied uniformly across the four practitioner groups. I should make it clear that, as now, the process of entry to the health authority list will be wholly separate from the processes through which a general practice selects new partners. 
 On the issue of unsuitability, to which Opposition amendments Nos. 170 to 174 relate, the clause will extend the grounds on which a health authority may refuse admission to its relevant practitioner list. Health authorities are already required to hold lists of all principal practitioners providing medical, dental, optical and pharmaceutical services. The new provisions will strengthen the power of health authorities to control the provision of family health services in their area. Crucially, they will allow health authorities to refuse a practitioner's entry to a list on the grounds of unsuitability or fraud. Unsuitability is capable of wide interpretation, so we will set out in regulations the criteria that health authorities must consider in reaching decisions on those grounds. 
 We intend that a health authority be able to consider a wide range of issues relating to the applicant, or, where relevant, to directors or other persons controlling a body corporate. They include criminal convictions, the adverse findings of a licensing or regulatory body, personal references, qualifications and previous career history—in other words, issues similar to those that any employer considers before engaging someone. We intend that barring from the list should be automatic where someone has been convicted for murder, is not on the relevant professional list—not quite as serious a matter, but a none the less suitable ground—or is subject to a national disqualification. In other cases, the decision would be at the health authority's discretion. 
 Before refusing a person's application on the grounds of unsuitability, we would expect a health authority always to consider criteria such as: the nature of any criminal offence or professional regulatory investigation; the length of time since any offence was committed or since the conviction or investigation; whether there are other offences to be considered; the penalty imposed on conviction or the outcome of the investigation; the relevance of the offence or investigation to his provision of family health services; the likely risk to patients or impact on the national health service or on confidence in it; and whether he has been refused admission to, removed from or suspended from other health authority lists, and the facts involved in such cases. 
 We intend to set those criteria in regulations. The list will not be exhaustive, in order to allow health authorities to apply other criteria that are relevant to each case. It will be for the authority to decide how much weight to attach to the criteria in the regulations and to other relevant factors.

Philip Hammond: The Minister is racing through his brief. The import of his comments seems to be that different health authorities could reach different decisions based on the same regulations. Does he really intend that a practitioner who applies in one health authority area and is rejected should then be able, quite properly, to apply in another area and be accepted?

John Denham: If a practitioner applied in one health authority area and was rejected, and no national disqualification was in force, he could then apply to a different health authority, which, under the clause, would have to take proper account of the fact that he had been rejected by the other authority. We do not seek to establish a system that leads to wide variations in performance, but it is possible that there may be grounds for refusal on a specifically local basis that would not apply in another area.

Philip Hammond: I am a little surprised by the direction of the Minister's comments. I point out to him the obvious danger involved. In a previous sitting, we discussed disparities in the general practitioner population in different parts of the country. Are not two distinct classes of health authority inevitable—those in popular areas, which are able with more care to pick and choose GPs for inclusion, and those that are desperately struggling to get enough doctors and not able to apply such choosy criteria? That may be the perverse outcome of the Minister's proposals.

John Denham: It would be a perverse outcome. That is partly why the individual practitioner has the right to appeal to the Family Health Services Appeal Authority and the health authority has the right to submit to the FHSAA that a disqualification relating to a person whom it did not want on its list should apply nationally. Moreover, it is reasonable to expect health authorities to take seriously the decision of another health authority—including those outside England, in Wales or Scotland. I stress to the Committee that the health authority is legally required to take into account any previous refusals and the other factors that I mentioned if no national disqualification is in place.
 I do not believe that a health authority would be able consistently to apply a higher standard because it was in a more sought-after area. At any hint of that happening, the practitioners affected would apply to the FHSSA, which would examine the case purely on the grounds of suitability. It would not take into account the popularity of the area where the GP hoped to be on the health authority list.

Philip Hammond: Does the structure of the clause mean that the Government have effectively given up on organisations such as the General Medical Council, the General Dental Council and the General Optical Council? Although the Minister has discussed mandatory grounds for unsuitability, he could cover those grounds if the likes of the General Medical Council are working properly by stipulating that nobody may be included on a health authority list unless they are also on the list of the appropriate body. If he has confidence in the ability of those bodies to function in future, it would be better to make the mandatory criteria relate to inclusion on their lists, and leave the health authorities with what he refers to as discretionary criteria.

John Denham: The difficulty is that it is possible to have a category of practitioner, for example a doctor, who is allowed to practise with or without restrictions by his professional body, but whom the NHS, as an employer or contractor, would not wish to have working for it. There are many professions in which the professional body allows individuals to practise, but that does not oblige an employer to give them jobs. It is possible to conceive circumstances in which somebody who was allowed, on professional grounds, to practise as a health professional by his regulatory body might not be seen as suitable to work in the NHS because other aspects of his conduct fell outside those grounds. However, it is possible that that person would be offered a job in the private health sector. This system gives greater protection by allowing the NHS to take its own decisions.
 There is a need, in practice, for the health service to be able to move quickly in response to problems that become apparent, without being dependent on the action of a third party. We are watching the discussions in the General Medical Council with interest. The council already has a president who is committed to tackling the backlog of cases on disciplinary action that have built up, and we look to that to be successful. Wide-ranging discussions are taking place on the reform of the General Medical Council, but it is inherently unsatisfactory for the NHS, as a provider of health services in Britain, to depend on the action of another body in order to deal with a disciplinary or other problem that could threaten patients. We look to the professional bodies to perform to the highest possible standards, but that does not obviate the need for these measures.

Philip Hammond: I am surprised that the Minister has given that explanation. When we considered the Care Standards Act 2000, I thought that the Government had grasped that they have a responsibility for maintaining standards across both the private and the public sector. However, he is now arguing, ``A doctor might not be good enough for the NHS, but he could still work in the private sector.'' Can he give an example of a situation where a doctor might properly and legitimately be expected to be competent to practise in the private sector, but not good enough for the NHS? How can the Government properly discharge their responsibility to maintain standards across both sectors, but allow that doctor to practise in the private sector?

John Denham: The NHS might not wish to employ somebody who has a record of fraud against it. A different employer might take a different view about whether that person should be employed. Depending on the circumstances of the fraud, neither opinion would relate directly to his clinical competence as a doctor or other health professional. I hope that the hon. Gentleman accepts the validity of that distinction.

Peter Brand: It is helpful to be able to ask the Minister questions as he goes along.
 I appreciate that the Minister would want the list to be more NHS-specific than the General Medical Council's list, but I do not see why it should involve any local variation. I understand that once a person is on the supplementary list of one authority, they automatically appear on the lists of others. Why should not principals be in the same position?

John Denham: That is likely to apply in the vast majority of cases. The FHSAA has the power to say on application that a person should not be on a list anywhere, and a health authority will know if they have been turned down somewhere else and will take that into account. It is conceivable that in certain circumstances the FHSAA would not consider the reasons for a person's disqualification from a local list to be sufficient grounds for a national disqualification. However, that is unlikely to lead to huge inconsistencies in treatment of individuals or of differing standards between one health authority and another.

Peter Brand: It may not lead to inconsistencies in treatment, but it will certainly lead to a burden of administration and bureaucracy. A great delay will be built into the system by which someone moves from one health authority to another. If they have the approval of one health authority, they should be eligible to apply for jobs elsewhere without going through a bureaucratic process.

John Denham: We had the option of replacing the current system of health authority lists. At the moment, someone who moves from one practice to another moves from one list to another—that transfer process already exists. Having considered the creation of a single national list for all GPs, we decided instead to build on the current system of health authority lists, while applying a more satisfactory test. That is the best way forward. No obvious body is capable of holding a single national list of GPs, and we would have had to create one for the purposes of the Bill.

Peter Brand: I am aware of the current system, but the Bill introduces something new in that suspension from one list will mean suspension from all other lists. The negative powers should be balanced against the positive powers.

John Denham: In practice, being on one list does not confer an automatic right to move to another one. However, if a practitioner who had not been subject to disqualification applied to move from the list of health authority A to that of health authority B, it would be extremely difficult—unless some new material fact came to light about their past practice or record—for health authority B to refuse them admittance to its list without immediately facing an appeal to the FHSAA. Although that is short of an absolute legal right to move from one list to another, a little consideration of how the system will operate suggests that it would be difficult to introduce hugely arbitrary variations.
 I turn to amendments Nos. 170 to 174 tabled by the hon. Member for Woodspring (Dr. Fox). The Bill introduces the concept of unsuitability. Although that is a broad term, I have illustrated the way in which we would require health authorities to consider action under the clause. 
 Amendments Nos. 170 to 174 take a different approach by seeking to include a definition of unsuitability. In preparing the Bill, we considered carefully whether to follow that approach by including a definition or setting parameters. We decided not to do so for a number of reasons, although there is an important qualification that I shall discuss in due course. There is a risk that, in time, any definition could prove over-prescriptive, and health authority powers could thereby be too narrowly or inflexibly drawn. As a result, cases could arise where, in everyone's view, action was necessary but could not be taken. 
 The issue of suitability extends beyond establishing whether a practitioner is qualified, or whether the health authority can prove that the practitioner would be a direct danger to his patients. All available information should be examined, and a decision on suitability for the job should be reached using criteria familiar to any employer. Health authorities should examine the available information and consider whether the practitioner in question has the qualities and attributes suitable to deliver medical, dental, ophthalmic or pharmaceutical services to our population. 
 There is considerable precedent for reliance on a broad term that is undefined in primary legislation. For example, employment rights legislation gives individuals under threat of redundancy the right reasonably to refuse their employer's offer of alternative employment if the post in question is not suitable. That legislation leaves ''suitability'' undefined, but over the years courts and tribunals have developed a body of case law. In practice, we envisage that the Family Health Services Appeal Authority will play a similar role.

Philip Hammond: I am sure that the Minister realises that we did not invent on a rainy Thursday evening the definition of unsuitability that amendment No. 174 would insert—it was taken from the Medical Act 1983. Does the Minister consider that definition too narrowly drafted, and does he plan to change it?

John Denham: If only the hon. Gentleman had listened when I said that there was one important qualification that I would discuss in due course. In fact, I am coming to it just about now.
 Although we are discussing clause 22, it is important to distinguish between the different roles of various clauses, such as those on refusing or permitting admittance to the list, removal from the list—which we shall discuss later—and suspension from it. In my view, the grounds for refusing admission to, or removing someone from, the list need to be sufficiently broad to capture all cases that might arise. Suspension, however, is a different process. Given its nature, suspension should be a neutral act. It is undertaken when serious allegations have not been proven, or while further investigations take place. 
 It is relevant to recognise that the wording of amendment No. 174 is drawn from a particular part of the Medical Act 1983. That wording is the test that should be applied by the GMC's interim orders committee, under which interim suspension orders can be made. I think it a good idea to import that wording into the clause dealing with suspensions. It sets a helpful precedent, and has attractions in defining the circumstances in which suspension might be appropriate. The wording captures both the notion of a risk to the patient, and that of a wider risk to the NHS or the public good. 
 I should like to signal now that when we discuss clause 26 we shall propose to adopt the wording of the amendment as the basis for a Government amendment to be tabled on Report, which will set out the circumstances in which a health authority may suspend a practitioner. That will leave this clause with a similar architecture of health authority powers to those in the Medical Act 1983. The test on suspension would be the wording used by the hon. Gentleman in his amendment. 
 The test for disqualification, removal and refusal to admit to a list will be a broader power. When the professional conduct committee of the General Medical Council decides whether to disqualify a practitioner, the grounds for serious professional misconduct are broader than those used for suspension. I hope that the hon. Gentleman will accept that we have recognised the force of his argument—if not in relation to clause 22, then certainly in relation to the suspension powers in clause 26. We shall table an amendment on Report to reflect that. 
 I now turn to the Government amendments. Amendment No. 116 introduces provisions to underpin the application process for medical lists. It provides for regulations setting out information that a doctor on the medical list must provide. We intend that those regulations will largely replicate health authority procedures. They will include matters such as medical and vocational qualifications, career history, declarations on criminal convictions and adverse regulatory body judgments, and references, which is all information that any good employer would require from someone seeking work. Being clear that we will make that check will deter dishonesty. 
 Amendment No. 117 addresses consistency. The Bill already provides for health authorities to refuse applications to join supplementary and services lists in certain circumstances. There would be no logic in providing grounds by which a person could be refused admission to the supplementary and services lists that did not equally apply to decisions by health authorities on admission to their existing medical list. The amendment clearly and unambiguously provides the means of introducing that. 
 The amendment also provides grounds on which a health authority could defer an application—for example, where it was known that the applicant was facing a criminal charge that would be likely to make him unsuitable to provide general medical services were he found guilty. Furthermore, the amendment allows regulations to be made to allow the Secretary of State to prescribe circumstances where a person cannot be admitted by a health authority to its medical list—for example, where the person had been convicted of murder or sentenced to more than six months' imprisonment.

Philip Hammond: The Minister has just given a precise example of what the regulations might say. Are we to infer from that that the Department of Health has draft regulations prepared? If so, would it be possible for members of the Committee to see them?

John Denham: To the best of my knowledge, we do not have a full set of draft regulations. However, there are issues that I shall refer to that have been discussed by the Government and the British Medical Association. Although those discussions are, as yet, unfinished, we have indicated our intentions. The hon. Gentleman will be aware that the specific point that I just mentioned is already incorporated in the test as part of the regulations introduced in the wake of the initial conviction of Harold Shipman. We discussed that matter in the House, and the provision merely reflects that for the sake of consistency in the regulations. Government amendments Nos. 119 to 126 make similar provisions for the lists for other professions.
 Finally, Government amendments Nos. 127 to 133 make minor consequential changes to the numbering of certain new provisions introduced by clause 24, to which we shall come in due course.

Philip Hammond: I suspect that we have now had most of the debate on the amendment through interventions on the Minister's speech, but I would like to make one or two additional points.
 It is incumbent on the Minister to explain why the Government have tabled so many amendments at this stage—at total of about 90 over the next few clauses. We understand that they have arisen from consultation and discussion with the representative bodies. We have no problem with that process having taken place, just as we—I can speak only for the official Opposition—have no problem with the amendments themselves. However, it is extraordinary that the Government apparently find it impossible to have sensible discussions with the people who know how these things work before publishing the Bill. Why do the Government consider it appropriate to publish a Bill without, one presumes, any real consultation with the bodies that they acknowledge need to be consulted, to consult them after it is published and then to table 90 amendments to three or four clauses? That does not seem the most sensible or efficient way to proceed. Indeed, it is slightly disconcerting in a Bill that makes provision to consult those very organisations before issuing regulations. Perhaps the Minister could give us some of the deep background to that peculiar train of events. 
 We recognise the driving force behind the clause. I suspect that the groundswell of feeling that such a measure was necessary started before the Shipman case, but that case has added impetus to the idea that we must deal with unsuitability. However, the Minister is getting himself into difficulty by confusing unsuitability in the sense of medics who must not be allowed to deal with patients with a much more amorphous concept of unsuitability based on a feeling that one would not want to employ a certain chap because he is not quite the ticket. The Minister's conflation of those separate notions is dangerous. Health authorities will be able to decide whether to include people on their list and might reject one chap on a Monday because he is a pathological serial killer and another on a Tuesday because he has been divorced twice or has something in his history that does not make him the most appropriate employee. There is a qualitative difference between such cases. Our definition of unsuitability would deal with that by allowing exclusion from the list only on grounds of real unsuitability—someone being a menace to themselves or to the public. 
 The Minister seems to be saying that there is a serious level of unsuitability and if someone falls into that category he or she must be debarred across the country. That is obviously right and proper. However, there is a lesser level of unsuitability, which would mean that someone might be unsuitable in Cheshire but suitable in Cornwall. We accept that there may be differences between the decisions of different health authorities, but such a system could have a slightly alarming outcome because—although the Minister denied it when I raised the matter with him earlier— it seems self-evident that in some parts of the country more people wish to practice as general practitioners than there are vacancies, while in other parts of the country there is a desperate need to get general practitioners into service. Such regions will typically be the most deprived parts of the country: inner city, run-down areas where health authorities are crying out for GPs. Frankly, it beggars belief that health authorities that are desperate for practitioners will not apply standards that are easier to meet than health authorities that have plenty of doctors and have no problem in providing a service whether or not they admit a given person to the list. Whether or not the Minister intends it—I feel certain he does not—so long as there is a shortage of GPs, the clause as it stands will serve only to heighten the inequalities in provision of service, instead of reducing them, which is the Government's stated objective. 
 I found it disturbing to hear the Minister repeatedly talking about employment practices and defining unsuitability to include factors that an employer might take into account when employing somebody. Returning to the discussion before lunch, we are seeking to be clear in our minds that the Minister is not attempting to undermine general medical services. GMS is not employment; it is not an employer-employee relationship, but a contractor-contracting relationship and precisely for that reason it is not appropriate to use the criteria that an employer would consider when he is employing someone. 
 I suppose that I should be pleased that the Minister has decided that amendment No. 174 have some applicability, however it is a shame that we tabled it in respect of the wrong clause. I understand the logic of his argument, but I think he is potentially making a serious mistake in confusing the two degrees of unsuitability—unsuitability because someone is dangerous either to himself or to patients and unsuitability because someone is not up to the standard that the health authority might like. We would have much preferred the two issues to be addressed separately. 
 If the Minister has confidence in the future of the General Medical Council and believes that the current programme of reform will be successful in restoring public confidence in that body, it would be right and proper for dangerous unsuitability to be dealt with by reference to whether a person is on the GMC's list. The Minister told us that it is necessary sometimes for the NHS to be able to move quickly in the case of a practitioner who is deemed unsuitable in order to suspend him from practice. It is equally important that the GMC is able to act quickly. Our objective should be not to put in place a separate mechanism subject to the Human Rights Act 1998 and to proper quasi-judicial practices within the NHS because we simply accept that the GMC will always be too slow, but to make the GMC process acceptable rather than duplicating the whole thing. 
 I accept the Minister's argument that there may occasionally be NHS reasons for not employing someone that would not be give the GMC reasons to exclude that person from the medical list. However, I cannot envisage—and the Minister could not give us any examples—circumstances where those NHS reasons would apply in one health authority area but not in another. We ought to take a general view that when Ministers bring Bills to Committees, giving themselves new powers, they ought at least to be able to present to the Committee an example of when such a power might be required. For the Minister to say that he cannot think of a single example of when a variation between one health authority and another might be justified invites us to question whether there is a need to allow such a discrepancy to arise.

John Maxton: Before I call the hon. Member for Isle of Wight, I should point out that the selection list marked ``3 Revised'', which was distributed before this sitting, is incorrect. We are using the selection list that was distributed before this morning's sitting marked ``3''. The cut-off time is now 7 o'clock and not 5 o'clock.

Peter Brand: Medical lists are maintained by health authorities but it is unusual not to get on a medical list if one is suitably qualified, has suitable prescribed experience, is registered with the GMC and has insurance. Those are the criteria. The Bill introduces another qualification—suitability for the job. If we are going to introduce that, I find it surprising that the criteria will not be set out in regulation or applied nationally. That can be done be through health authorities, as agents of the Secretary of State, but I should have thought that if one health authority approves, that approval should be automatic for all others. I can see real difficulties through delay, for instance. If one applies for a partnership in a practice that covers two or three health authorities, by the time one has gone through the two or three processes to determine suitability, the job may have gone. The Government are missing an opportunity to streamline the approval system as they are streamlining the disqualification or the suspension system, which I fully support.
 As the hon. Member for Runnymede and Weybridge (Mr. Hammond) said, suitability has been a matter for the applicant's prospective partners. They should be the best judges of whether a suitably qualified and registered person is right for that locality. That job is done by the health authority for single-handed practices, and I would assume that it is done by the health authority or the agency running a personal medical service project, if it is to be delivered through a directly employed practitioner. We are creating an extra barrier for people who may not fit the idealised picture of the family doctor. They may not get approval in the health authority area except through an appeal mechanism, by which time the vacancy may well have gone. It is likely to ghettoise people into the less attractive areas. 
 The other issue that the Minister has not addressed is whether there will be approval of a list and whether it will vary with the type of practice that is being considered. One of the powers that the Minister does not have is the ability to deal with a practitioner who falls out with his partners and establishes a single-handed list. There are apparently no powers in the Bill to prevent. Consequently, people who are excluded from a partnership because their mental health is unstable, or they have problems with alcohol or drugs, although not serious enough to warrant formal notification to the authorities, are made even more vulnerable.

Philip Hammond: The hon. Gentleman emphasised the fact that suitability as a partner in the practice should be a decision for the other partners. Does he agree that that abrogation of that power to the health authority looks suspiciously like yet another attack on the independent status of GMS contractors?

Peter Brand: That is why I am worried about the effect that clause—even with the amendments—may have on the way in which practitioners are distributed around the country. I want everyone to have an equal opportunity to apply for partnerships in all parts of the country. Creating the artificial device of having suitability determined by a health authority, rather than by the people who have to work with the partner that they are appointing, cuts right across the concept of partnership and independent contractor status. In the case of directly-employed doctors, the health authority would be acting as an employer so suitability criteria are applicable.
 On another minor issue, can I check with the Secretary of State that clause 22 and the subsequent clauses apply only to medical, dental and ophthalmic practitioners? If so, where does that leave practices that are led by nurses? Are we likely to see a situation where an unsuitable person may be in charge of a practice, but cannot be removed from a list or any arrangement of that sort? I have never quite understood the accountability relationship between a nurse-led or lay-led practice employing doctors. Who is the responsible person in that instance? 
 In the Care Standards Bill we made it quite clear that the employing body, for instance a cosmetic surgery clinic, had a responsibility for what happened in that clinic and it was not only the doctors who were accountable. I cannot see how the Bill addresses that issue.

John Denham: I shall endeavour to deal with as many of those points as possible. The hon. Member for Runnymede and Weybridge asked, quite reasonably, was why the Government found it necessary to table so many amendments so late in the proceedings. As I said the other day, it is regrettable.
 The essential issue that influenced the drafting of the Bill has been some ambiguity in the extent to which it was necessary to take primary legislative powers in order to establish the lists that are under discussion. We decided—rightly, I think— that it would be clearer and more secure to take primary legislative powers, and that is what we have done. However, the timing has meant that some amendments, particularly those that seek to ensure consistency across the different categories, were tabled later than I would have wished. 
 The process means that there has been considerable discussion on various elements of the lists, the criteria and so on with the BMA and other relevant bodies, pre-dating the final drafting of the legislation—although I do not want to give the impression that all those negotiations and discussions are complete. 
 A number of issues have been raised including whether the provision will lead to greater inequality. I do not believe that it will. I think it will be clear that all health authorities have to act with natural justice and in a fair and proper manner in order to meet the definition in the Bill in respect of suitability for inclusion on the list. The appeals authority is there to back that up. 
 It is greatly to the advantage to primary care services for health authorities to know—much more unambiguously than in the past— that they have a direct responsibility for maintaining standards and for taking responsibility for whether practitioners are on their lists. I believe that some of the problems that arose in the past stemmed from a feeling in health authorities that although they maintained lists, those lists applied only to some of the practitioners and it was never quite clear who was responsible for the rest. They felt that perhaps the GMC ought to sort it out, and that the NHS tribunal involved quite a complex process. The lack of front-line responsibility for the quality of doctors and other health professionals working in a health authority area is a significant weakness. This Bill represents an important step forward. 
 The hon. Member for Runnymede and Weybridge quite fairly said that it was a bit poor for Ministers to put a measure before the Committee without being able to think of a single worked example to illustrate it. However, he will understand my caution with worked examples because there is always a residual fear that in 10 or 15 years' time a High Court judge will look back through the Committee Hansard , pull out an example and say, ``That is the precise definition of what the law was meant to say because it is what the Minister said on the day''. 
 So there is a natural nervousness in doing this, and I will heavily preface what I am about to say as a purely illustrative example of what might happen. Let us suppose that a GP ran into difficulties in one local area because, as the owner of a nursing home, it became apparent that his referral practices were unduly influenced by his financial interests in the nursing home. It is possible that, after proper investigation, that led to his subvention and disqualification from a health authority list. It might be that the appeal authority, while considering that that was a perfectly reasonable decision for the health authority to take in that particular case, felt that there were some local peculiarities in respect of that health authority, that GP and that set up, which would not necessarily lead to a national disqualification. It is therefore possible that another health authority, in an area where the individual concerned had no financial interests, would take a different view. I have to be careful about saying whether that sequence of events would happen or whether that is precisely the right example, but it serves to illustrate how it is possible for the system to operate in that way.

Peter Brand: I fully accept the Minister's reminder that we are not here to judge a particular case, but his hypothetical example suggested a reason not to have someone on a local list, and there have got to be jolly good reasons to do that. If the reasons are good—if there were corrupt practices, which are against the regulations as they are at the moment—they should be grounds for a national disqualification. I really cannot accept the Minister's example.

John Denham: It would probably not do us much good to pursue the hypothetical example to its final conclusion, but it is sufficient to illustrate the possibility. There are unlikely to be a huge number of inconsistent decisions, for all the reasons that I set out earlier, but I have given a possible. It is far more likely that where someone is judged unsuitable to be on a list, and that decision is upheld by the appeal authority, either it is likely to be applied across the country, or health authorities will look into the background and apply decisions in a consistent way.

Philip Hammond: The Minister touched briefly on the question of inequality of distribution, and said he did not believe it would happen. However, I do not think that he gave any reason for that. It seemed to me that the argument that I set out was persuasive, superficially at least, and I was looking forward to hearing him demolish it, but he has not done so.

John Denham: The fact that all health authorities will be clear that they are seen as having a much more front-line responsibility for the quality of services than they felt that they had in the past will mean that they are unlikely to lower their standards and say that they are willing to put up with a dodgier quality of doctor than elsewhere. That shift of outlook and responsibility is an important element of the new system, and it does provides protection against the circumstances to which the hon. Gentleman referred.
 The hon. Member for the Isle of Wight (Dr. Brand) asked specifically about nurse-led practices. He probably had in mind a practice where a nurse holds the contract for a PMS practice with the local health authority but employs the general practitioners. It is the general practitioners in that practice who would be on the list that we are discussing. There is no provision in the Bill for creating a list of nurses or other health practitioners outside the four professions currently covered by the part II provisions in the 1977 Act. It is certainly the case that the doctors in a PMS practice, even if it is nurse-led, are subject to the same need to be on a list, and the same scrutiny powers as any others. I hope that the hon. Gentleman is reassured on that point.

Peter Brand: The Minister has explained the issue clearly, but I am not reassured. Should there not be some way within the powers of the Bill to make the employer accountable in the same way as the employee? It is quite clear that the employer can affect the way that services are delivered by his or her employee, in the same way as we discussed in relation to the Care Standards Act 2000.

John Denham: I will reflect on that point. I believe that the powers in the Bill are sufficient and that the nature of the PMS contract with the health authority would enable other deficiencies in the running of a practice to be addressed. I have not seen the need to specifically address a new category. One category in the Bill that we have identified is commercial corporate bodies—dental corporations—that are dealt with in a later clause. I will reflect on the points made by the hon. Member for Isle of Wight, but I am satisfied by what I have so far seen that the protections are adequate.

Philip Hammond: If I understand the exchange that has just occurred, the Minister is saying that in cases whereby the practitioner is the principal, he must be on the health authority's list. If the nurse is an employee, she would presumably be required to be on the supplementary list.

John Denham: No. All doctors have to be on a list. If they are principals, they will be on the list of principals, and if they are non-principals, assistants or locums, they will be on the relevant list. Whether they are the principal in a PMS practice or whether they are a salaried doctor or whatever their employment status within the PMS practice, they will be on the relevant PMS list. There is not a list for nurses working in primary care. We have not taken the legislation further than those groups or professions that are currently covered by part II of the Bill.

Philip Hammond: At the risk of getting ahead of ourselves, perhaps it would help if I clarified the issue. In relation to the supplementary list, the Bill states
persons approved...for the purpose of assisting in the provision of general medical services. 
Does that mean that ``assisting'' must be defined narrowly, and would not include, for example, practice nurses, who, in the everyday sense of the word, are ``assisting'' in the provision of services?

John Denham: I believe that that is right. I will ensure that we cover it adequately when we get to that point. We need a specific rather than a colloquial definition.
 Amendment agreed to. 
 Amendments made: No. 117, in page 15, line 8, leave out from beginning to end of line 18 and insert— 
`(a) after subsection (2), there shall be inserted— 
 ``(2A) The regulations may also make provision in relation to— 
 (a) grounds on which a Health Authority may, or must, refuse to nominate or approve a medical practitioner for appointment to fill a vacancy (including his unsuitability for inclusion in their medical list, and grounds corresponding to the condition referred to in section 49F(3) below); 
 (b) information which must be supplied to a Health Authority by a medical practitioner seeking such nomination or approval (or by arrangement with him); 
 (c) the supply to a Health Authority by such a medical practitioner of a certificate of the kind referred to in section 29A(4A)(b) above; and 
 (d) the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about such medical practitioners, and refusals by the Health Authority to nominate or approve them.'';
(b) in subsection (3), after paragraph (a) there shall be inserted— 
 ``(aa) grounds on which a Health Authority may defer a decision whether or not to nominate or approve a medical practitioner for appointment to fill a vacancy;''; and
(c) after subsection (3) there shall be inserted— 
 ``(3A) If regulations made by virtue of subsection (2A)(a) provide that a Health Authority may refuse to nominate or approve a medical practitioner for appointment to fill a vacancy, they must provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''
 No. 118, in page 15, line 21, leave out `(5)' and insert `(7)'. 
 No. 119, in page 15, line 21, leave out `and' and insert— 
`( ) after subsection (1) there shall be inserted— 
 ``(1A) The regulations may include provision as to— 
 (a) information which must be supplied to a Health Authority by, or by arrangement with, a dental practitioner or dental corporation included or seeking inclusion in a list referred to in subsection (1)(a); and 
 (b) the supply to a Health Authority— 
 (i) by a dental practitioner who is included, or seeking inclusion, in such a list, or 
 (ii) by a director of a dental corporation included, or seeking inclusion, in such a list, 
 of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act.''; and'.
 No. 120, in page 15, line 24, leave out from `provision' to end of line 34 and insert 
`in relation to grounds on which a Health Authority may, or must, refuse to include a dental practitioner or a dental corporation in a list referred to in subsection (1)(a) (including his, or its, unsuitability for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below). 
 (5) Those regulations may make provision in relation to criteria to be applied in making decisions under the regulations. 
 (6) If those regulations provide that a Health Authority may refuse to include a dental practitioner or dental corporation in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.
 (7) Regulations may provide for grounds on which a Health Authority may defer a decision whether or not to grant an application for inclusion in a list referred to in subsection (1)(a). 
 (8) Regulations may make provision as to the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about dental practitioners and dental corporations seeking inclusion in such a list, and refusals by the Health Authority to include them.'.
 No. 121, in page 15, line 40, leave out from `provision' to end of line 7 on page 16 and insert 
`in relation to— (a) grounds on which a Health Authority may, or must, refuse to include a medical practitioner or an ophthalmic optician in a list referred to in subsection (1)(a) (including the unsuitability of the applicant for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below); 
 (b) information which must be supplied to a Health Authority by a person included or seeking inclusion in such a list (or by arrangement with him); 
 (c) the supply to a Health Authority by an individual— 
 (i) who is included, or seeking inclusion, in such a list, or 
 (ii) who is a director of a body corporate included, or seeking inclusion, in such a list, 
 of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act; 
 (d) grounds on which a Health Authority may defer a decision whether or not to include a person in such a list; 
 (e) the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to include them; and 
 (f) criteria to be applied in making decisions under the regulations. 
 (3) If regulations made by virtue of subsection (2)(a) provide that a Health Authority may refuse to include a person in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.
 No. 122, in page 16, line 12, leave out from beginning to `and' in line 17 and insert— 
```(f) as to other grounds on which a Health Authority may, or must, refuse to grant an application (including the unsuitability of the applicant for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below); 
 (g) as to information which must be supplied to a Health Authority by a person included, or seeking inclusion, in such a list (or by arrangement with him); 
 (h) for the supply to a Health Authority by an individual— 
 (i) who is included, or seeking inclusion, in such a list, or 
 (ii) who is a director of a body corporate included, or seeking inclusion, in such a list, 
 of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act; 
 (i) for grounds on which a Health Authority may defer a decision whether or not to grant an application; 
 (j) for the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to grant such applications; 
 (k) as to criteria to be applied in making decisions under the regulations (other than decisions required by virtue of paragraph (d)).'','.
 No. 123, in page 16, line 19, leave out from `regulations' to end of line 23 and insert 
`made by virtue of subsection (3)(f) provide that a Health Authority may refuse to grant an application, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.
 No. 124, in page 16, line 25, leave out `(2A)' and insert `(2B)'. 
 No. 125, in page 16, line 26, leave out `(2AA)' and insert `(2BA)'. 
 No. 126, in page 16, line 27, leave out from beginning to end of line 35 and insert— 
`(a) as to grounds on which a Health Authority may, or must, refuse to grant an application for inclusion in a list of medical practitioners referred to in subsection (2A) (including his unsuitability for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below); 
 (b) as to information which must be supplied to a Health Authority by a medical practitioner included, or seeking inclusion, in such a list (or by arrangement with him); 
 (c) for the supply to a Health Authority by a medical practitioner who is included, or seeking inclusion, in such a list of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act; 
 (d) for grounds on which a Health Authority may defer a decision whether or not to grant an application for inclusion in such a list; 
 (e) for the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to grant such applications; 
 (f) as to criteria to be applied in making decisions under the regulations. 
 (2BB) If regulations made by virtue of subsection (2BA)(a) provide that a Health Authority may refuse to grant an application for inclusion in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.—[Mr.Denham.]
 Clause 22, as amended, ordered to stand part of the Bill.

Clause 23 - Dental Corporations

Question proposed, That the clause stand part of the Bill.

Desmond Swayne: Were we still labouring under the ancien regime and had we decided, under the procedures that until 6 December governed these Committees, properly to scrutinise the Bill and subject clause 23 to a thorough examination, this would be a stretching process.
 Yesterday, I sought a briefing from the British Dental Association, which replied to me in an e-mail message, saying that it 
does not object to the amendment— 
by which it means the clause— 
to allow dental corporate bodies/companies to provide General Dental Services and to contract with Health Authorities for services. Some questions remain about the practical application of this, particularly in relation to discipline within the GDS Regulations, and these will be discussed with the Department of Health. 
The Minister will no doubt look forward to those discussions, because they will be had with him, rather than in Committee. However, I have a couple of questions about the clause. Why is there no provision for ophthalmology or pharmacies similar to the arrangements that we are making for corporate bodies in respect of dentists?

Peter Brand: Or doctors.

Desmond Swayne: The hon. Gentleman is correct. I was prompted to ask that question by a representation that I received from Lloyds Pharmacy, which is worried about clause 26 and the provisions for disqualifying practitioners. It says:
 While we welcome any measure which enables individual misconduct to be dealt with effectively, we are concerned that this Clause could enable entire pharmacies or chains of pharmacies to be prevented from operating as a result of the misconduct of an individual pharmacist. Our concern hinges on what the Government means by ``person'' in the Clause. 
It is referring to clause 26 and goes on to say: 
 If a ``person'' is defined as being a single individual only, the Clause has our full support. 
 If a ``person'' is defined as being a corporate body, it seems to us this could mean that, should a single employee misbehave (ie an individual pharmacist within the corporate pharmacy ``person''), an entire company could end up being removed from a Health Authority's list. 
That would be highly inequitable. That confusion could be avoided if there were a provision for pharmacists and ophthalmologists similar to that in clause 23.

John Denham: Clause 23 deals with dental corporations. Most dental practices are owned by individual dentists or partnerships, but a limited number are owned by corporate bodies that employ the dentists. Boots has recently acquired a corporate body, and the largest, Integrated Dental Holdings Ltd., has a multi-million pound turnover.
 Experience shows that limited liability status helps such bodies to raise capital for investment in building and equipping new dental surgeries, so we want to encourage their growth while ensuring that patients have the same protection that we provide for patients of practices directly owned by dentists. 
 It may not be commonly known that the number of corporate bodies is currently limited by restrictions in the Dentists Act 1984. Some trading is possible, and new bodies have recently entered the field by buying shell companies, which have ceased to trade. The restriction dates back to the Dentists Act 1921, when the number of corporate bodies was frozen because of concerns that clinical and ethical requirements might be overridden by commercial interests. However, there have been major improvements in the safeguards provided by company law and, with the introduction of the NHS, by the disciplinary controls that we are discussing and enhancing today. 
 We have positive experience of the widespread involvement of corporate bodies in providing pharmaceutical and optical services for NHS patients. The hon. Member for New Forest, West asked why there was a provision about dental corporate bodies and not others. It is because there is an existing provision for the ophthalmic profession, and there are pharmaceutical regulations that list corporate bodies, but dental corporate bodies are not covered. The proposal corrects that anomaly.

Peter Brand: For completeness, will bodies providing medical services under PMS be mentioned?

John Denham: The contracts that are held for PMS are not analogous to those held by the commercial trading organisations referred to in respect of pharmacies, opticians and dentistry. I am not sure that it is the same issue.

Peter Brand: There is a move towards one-stop shops, especially within large chemist chains, which provide ophthalmic, dental and medical services in walk-in clinics. Thus there must be parallel arrangements for corporate bodies that may want to move into that market.

John Denham: I am not convinced that that is so. People provide PMS either under a GMS contract or a PMS contract under the National Health Service (Primary Care) Act 1997. The arrangements that are allowed for the provision of medical services are fully and adequately covered.
 The hon. Gentleman may be suggesting that some time in the future there will be a rise of corporate medical organisations contracting commercially to the NHS, but that is not the case now, nor is it on the horizon. It is not something that the Bill will encourage.

Philip Hammond: Will the hon. Gentleman give way?

John Denham: No, as I want to make some progress.
 We plan to remove the restriction in the Dentists Act 1921 through enabling powers included in the Regulatory Reform Bill currently before Parliament. The extensive consultations and parliamentary scrutiny proposed in that Bill mean that it will be the end of the year before the change comes into effect. 
 First, however, we must guarantee NHS patients the same protection whoever treats them. The clause will protect patients who receive dental care from corporate bodies by enabling health authorities to contract with a corporate body for the provision of general dental services in the same way as they contract with individual general dental practitioners. As a result, health authorities will be able to remove from their lists all dental providers, including corporate bodies and/or the dentists they employ, if there is evidence that they are unsuitable. For example, directors of a corporate body who are not dentists may be involved in fraudulent abuses of the fee regulations or they may fail to provide adequately equipped surgery premises. In such cases, the health authority could remove the company from its list. I hope to table amendments on Report that will prevent the same directors reappearing as a new company and going on to the list. I hope that that will allay the hon. Gentleman's concerns. 
 Any response should be proportionate. The failure of a dentist in a corporate body to provide an adequate service in one part of the country should not usually lead to the entire organisation being shut down or deemed unsuitable, and the measure's appeal provisions will prevent that. However, if there were wrongdoing at the top, that option would be borne in mind. 
 Question put and agreed to. 
 Clause 23 ordered to stand part of the Bill.

Clause 24 - Declaration of financial interests, gifts, etc

Philip Hammond: I beg to move amendment No. 184, in page 17, line 29, after `gifts', insert `above a specified value'.

John Maxton: With this it will be convenient to discuss the following amendments: No. 175, in page 17, line 30, at end insert
`or to be received, including any bequests in favour of the practitioner by patients'.
 No. 181, in page 17, line 30, at end insert— 
 `(5AA) Any regulations under (5A) above which specify a value above which gifts must be declared, shall specify such value by reference to the limits from time to time set by the Ministerial Code for such declarations by Ministers of the Crown.'.
 No. 176, in page 17, line 39, at end insert 
`or to be received, including any bequests in favour of the practitioner by patients'.
 No. 177, in page 17, line 39, at end insert— 
 `(1AA) Any regulations under (1A) above which specify a value above which gifts must be declared, shall specify such value by reference to the limits from time to time set by the Ministerial Code for such declarations by Ministers of the Crown.'.

Philip Hammond: I do not know whether other hon. Members have noticed the wonderful howler in paragraph 105 of the explanatory notes, which talks about doctors normally being obliged to
refuse to all patients except those of low intrinsic value. 
In the run-up to the general election, I am already working on how selectively to quote that and turn it into a Government definition of a patient of low intrinsic value. 
 The five amendments would insert a de minimis concept into the arrangements, so that they would refer to gifts within a certain value, eliminating a bureaucratic structure for gifts of minimal value. 
 First, the amendments would ensure that expected future benefits were declarable. All members of the Committee will be familiar with that concept. The rules on declaration of interests in the House include declarations of any expectation that the Member might have of a future financial benefit. Especially given the concerns raised by the Harold Shipman case, the expectation of future financial benefit is a material consideration, so we have made specific reference to bequests. 
 Secondly, the amendment, as tabled, may not do the trick. However, I hope that the Minister will accept the suggestion that practitioners who are aware that they are beneficiaries of a patient's will should register that fact. It may be argued that many doctors are genuinely unaware that they are beneficiaries of people's wills. I find the idea slightly strange, but I am told that it is not uncommon for people to make general practitioners beneficiaries of their wills. However, when practitioners are involved in persuading the patient to draw up a will or in helping to redraft the will, they will have knowledge of it and that should be required to be registered.

Peter Brand: I am sure that the hon. Gentleman would not be surprised to learn that medical practitioners are often promised future benefits in wills that never arrive. I have problems with the hon. Gentleman's concept because to publish the fact of expectations will put unreasonable pressure on patients, who will feel that they are obliged to fulfil their perhaps rash idea, which they may have had at some soft moment.

Philip Hammond: I understand the hon. Gentleman's point. However, in view of the events that have occurred, the fact of expectation is material and relevant. If a general practitioner stands to benefit financially from the demise of a patient, that fact should be brought to the notice of a responsible body—the health authority, in this case—if not placed within the public domain. It is a relevant fact that should be recorded somewhere. However, we will hear what the Minister says about that amendment before we continue our debate.
 The third purpose behind the amendments is to set the value threshold by reference not to a specific monetary amount but to the threshold for declaration of gifts by Ministers of the Crown. That seems entirely equitable and reasonable. That threshold is £125. No doubt the Minister would argue—and I would not disagree with him—that Ministers of the Crown would not be likely to be influenced by receiving a gift, certainly not a gift with a monetary value of less than £125, and are mature enough to be able to accept small gifts without it distorting their powers of judgment. 
 One is entitled to ask why medical practitioners are not assumed to be similarly discriminatory and able to receive small gifts without being unduly or inappropriately influenced by them. The case in logic for linking the monetary threshold to the monetary threshold that is applied to politicians is unanswerable. It would be grossly insulting to doctors to suggest that they are of a different calibre when it comes to making moral judgments about financial gifts or incentives that they are offered. 
 I emphasise that the amendment does not require the threshold to be set at the same level as for Ministers of the Crown, but merely by reference to it. It could be twice the level for Ministers of the Crown or half the level. The amendment would also have the singular advantage that, as the ministerial code levels were adjusted over time, there would be an automatic updating to take account of inflation and/or society's changing perception of the corruptibility or otherwise of those in positions of office. I think that has benefits. 
 I acknowledge that this group of amendments is not technically perfect. Indeed, due to nothing other than laziness on my part, they address only general medical services and general dental services; I could not bear the thought of writing out the same amendments twice again in order to cover ophthalmic and pharmaceutical services. I hope the Minister will take them as pointing in that direction. We would like to hear his views, and if he believes the amendments have any merit, we could perhaps return to them at a later stage in the Bill's progress and make sure that they are technically perfected.

Peter Brand: I support the spirit behind these amendments. The issue of gifts to practitioners is extremely difficult. It is churlish to turn down a gift, especially when people have made a special effort. In the appropriate season, we are frequently given a brace of pheasant. We particularly appreciate it when it comes from the wife of the gamekeeper, because she prepares them for the oven. I am afraid that the nobs who shower me pheasant, do so literally—it is difficult to know when they were shot, but that is good for anatomical skills.
 However, there is a real difficulty with the issue of gifts having a reasonable value, because people appreciate gifts, and that works both ways. We have a large orchard and have large bowls of apples in the waiting room. I am not trying to keep people away by giving them an apple, and nor am I trying to bribe them to come. It is an interaction between communities and the people who serve them. It is important for there to be a monetary value, and for us to distinguish between gifts that are of personal benefit and gifts to the practice, which predominantly benefit other patients or other staff. I cannot see anything in this clause that helps to deal with that particular issue. 
 I know that there are rules and regulations for trusts. People often want to express their gratitude for the hard work done in a hospital, and a box of chocolates for the nurses is appropriate, as is a donation to the league of friends. I hope that, when the regulations are drawn up, the Minister will bear in mind the fact that independent contractor have a particular difficulty. Anything that is bought out of gifts they do not have to buy themselves. That could be interpreted as extra moneys going towards practice facilities that are of direct benefit to the practitioner, so perhaps they should be spent on extras, such as sound systems and extra chairs.

John Denham: Although I have no fundamental objection to amendment No. 184, it is unnecessary because we intend that regulations should specify a value for gifts. I will leave it to the hon. Member for Runnymede and Weybridge to decide whether he wishes to press me on the point, but I hope that he will be satisfied with that assurance.

Philip Hammond: The Minister will know that the pharmaceutical industry's voluntary code sets a limit of £5 on gifts to general practitioners. What monetary value does he have in mind?

John Denham: Those matters are for discussion with the profession, but it is well known that the figure of £25 has been bandied about in discussions with the BMA over recent months. The figure has not been finalised, but it gives an idea of the order of magnitude involved. We will need to return to parliamentary counsel on the issue. I would prefer not to bring forward an amendment on that on Report, but I have no fundamental objection to the notion of a specified value.
 I agree that a comparison of the proposal with the ministerial code of conduct appears at first sight to suggest that it costs five times as much to buy a Minister as it does to buy a general practitioner. I would not want to argue that that is an example of market forces at work. It is obviously not a relevant comparison. I shall make a few points about the position of Ministers and hon. Members. My understanding of the ministerial code of conduct is that we are required simply to refuse gifts that might give rise to concerns about their effect on our impartiality, and that we must give back or buy gifts with a value of more than £140. Members of Parliament must declare any gift of more than £125 in the Register of Members' Interests, which is open to the public. There is an important difference between a register that any member of the public can look at, and a register such as we propose for GPs, which we have never suggested should be open to the public. 
 A more relevant comparison would be with the guidelines for employees in the NHS—although I acknowledge that there is some difference in the position of those working in hospitals and that of general practitioners. We have sought to achieve the right balance and to have a broadly consistent approach. We have just published guidance on commercial sponsorship within NHS hospitals. Sponsorship was defined as funding from an external source, including funding of all or part of the costs of members of staff, NHS research staff, training, pharmaceuticals, equipment, meeting rooms, costs associated with meetings, meals, gifts, hospitality, hotel and transport costs, provision of free services, buildings or premises. It includes among its requirements the declaration of gifts and other forms of sponsorship valued at more than £25, while the proposal that we are discussing requires that gifts from pharmaceutical companies should be declared. The BMA strongly supported that guidance, stating that the vast majority of GPs would be more than willing to comply with it. 
 Our guidance on commercial sponsorship does not replace the guidance issued to the NHS under the previous Administration: ``Standards of Business for NHS Staff''. That document addressed the difficult issue of gifts from patients, and made it clear that NHS staff, including doctors, should decline all gifts from patients other than those of low intrinsic value. I agree with the hon. Member for Isle of Wight that in the vast majority of cases—with the exception of small gifts such as a box of chocolates or flowers—staff routinely encourage patients to make donations to a league of friends or a local appeal, which is what grateful patients often do.

Philip Hammond: The Minister fails to distinguish between a personal gift to a member of staff and a gift made for the benefit of the hospital or, if is it to the GP, for use in the practice. Does the Minister accept that there is a relevant distinction between a bottle of whisky and a box of sphygmometer cuffs?

John Denham: Yes, of course. I do not know what the position is for NHS staff if patients personally present them with a gift of hospital equipment, because that usually goes through a different route. However, it is important to note that the emphasis of these provisions is on declaration within the organisation rather than refusal of a gift. What we will end up with as a result of these regulations is a system of disclosure akin to that for NHS staff. Declarations of financial interests will have to be made, and that is right. It will be known whether a GP owns a private nursing home to which he refers patients, whether he has an interest in a pharmacy, or whether pharmacists and opticians have similar possible conflicts or overlaps of interest. The move is toward an appropriate consistency.
 What attitude should we take towards gifts from patients to GPs? If we took an approach that was wholly consistent with the position of staff employed in the NHS, we would have to require that all gifts should be refused unless they were of low intrinsic value. Although it is hard to define, the relationship between a general practitioner and his patients over a long period is often somewhat different. That is why we are requiring declaration of gifts over a certain value, rather than taking the harder line of requiring GPs to refuse gifts, as would be the case in a hospital situation. 
 Very often the relationship between GP and patient is highly positive, but it can also be a potentially problematic relationship between a powerful GP and a vulnerable patient. Having this information available is a useful safeguard, so that if grounds for concerns arose, the pattern could be examined. 
 The hon. Member for Runnymede and Weybridge asked me about his amendment on bequests. I understand his point, and I certainly see why the information might be of advantage. However, I have identified a host of quite considerable practical difficulties in running such a system. I make no promise about introducing further measures, but I shall give the issue further consideration. I accept that such information could be useful, but I would not want to introduce a system that could not work in practice, or that could be discredited.

Hilton Dawson: I believe that GPs should be treated exactly the same as other professionals working in the NHS and in other care fields. Although it is nice to think of the ruddy, rural GP receiving a brace of pheasants from his patients now and then, we are trying to modernise the NHS. Everyone is aware of the vulnerability of patients, and of the relationships that can develop between people who are being looked after and their carers. I do not see why GPs should be in a different category. I have nothing against GPs: I value their professionalism as much as that of anyone else in the health service or in the social care field. If we want consistency, it should not be appropriate for patients to give those who care for them any more than the normal tokens of politeness and decency. We should ponder on that.

Peter Brand: I am happy to respond to the hon. Member for Lancaster and Wyre (Mr. Dawson), whose opinions I normally value a great deal. There is an enormous difference between being a general practitioner, who has to live in the community that he serves, and a doctor, who has to work in an institution or hospital. I have known most of my patients for more than 20 years, and the gifts do not all go in one direction. If Mrs. Salmon does not bring us some smoked salmon on Christmas eve, we might go hungry because we had planned on having it; but she may join us instead for a meal on boxing day. How can we resolve that difficulty? Not only is she a very good friend, she has been my patient for 25 years. It can be difficult, because the gifts are not given for a particular episode of care. I hope that such relationships will continue, although I suspect that they are getting fewer. I now get more bottles of sherry than I used to receive of whisky.

Philip Hammond: The miserable puritanism of the hon. Member for Lancaster and Wyre does not appeal to me. I hope that the Minister agrees that it should be possible to modernise the NHS without losing the human touches that characterise it. Relationships between those who work in an organisation and those who use it exist also between doctors and their patients.

Adrian Bailey: In view of the hon. Gentleman's opinion of my hon. Friend's miserable puritanism, I take it that he disagrees with his party's leader that the Government should be purer than pure?

Philip Hammond: That is slightly—[Interruption.] As my hon. Friends said, Labour Members might wish to steer clear of such subjects.
 Although he has not enjoyed the pleasure of our Committee discourses before, the hon. Member for Lancaster and Wyre will not have been shocked or surprised by my comments—any more than I have been shocked or surprised by some of the things that he has said about me. The trick is to keep the insults in order, as I am sure the hon. Gentleman would agree. 
 I am grateful to the Minister for undertaking to look into the matter of bequests. I realise that it will not be easy, but that potential route of abuse has been shockingly highlighted by recent events. I urge the Minister to reconsider a link between the ministerial code and the threshold for declaring the value of gifts. I wonder whether we need to distinguish between gifts for personal use and those that are given for the benefit of service. For example, an item given to a hospital that is intended to be kept on the ward and used would not have to be medical equipment. I accept that patients do not arrive bearing boxes of medical supplies in gratitude for their treatment, but they sometimes buy relatively expensive pieces of equipment. It is not uncommon for patients to want to give something to the hospital; someone whose child has been treated in a paediatric ward may want to give some toys or curtains to brighten up the place. It would be a miserable NHS if it was not considered appropriate to accept such small tokens, not for the personal use of any member of staff, but for the general benefit of staff and patients.

Hilton Dawson: I enjoyed the hon. Gentleman's good humour, but I was not arguing that small gifts and the odd kindnesses of ordinary human relationships should be removed from the equation. I had in mind bequests and the substantial amounts that people sometimes give.

Philip Hammond: I am grateful for that clarification. There are probably three categories: one is minor, insubstantial personal gifts and another more major gifts and financial interests of a personal nature. The Minister touched on a GP's interest in a pharmacy. I must admit that I was surprised—that is putting it mildly—when I discovered that the General Medical Council allows general practitioners to have interests in pharmacies that may dispense the scrips that they issue. That is a highly relevant financial interest and the health authority should know about it in order to be able to monitor the doctor's prescribing activity and ensure that it is not irregular.
 The third category of gift is that not intended for the personal use of the recipient. That would clearly not include a pheasant, but it might include a small piece of equipment or something to brighten up the surgery. I accept that there is a difficult line to tread in the case of GMS, because without such a gift the practitioner might have to dig into his own pocket to buy the equipment. However, it seems to me and to many in the pharmaceutical industry that there should be a distinction between something of benefit to the practitioner and something that will be used in the practice to the mutual benefit of both parties. Its use in the practice will benefit patients and practitioners, but it also benefits the pharmaceutical company whose name it bears, by providing advertising. 
 Yesterday, I encountered an example of what I am describing. Let me own up; I was given a copy of a medical textbook by a pharmaceutical company. The cover value is $25. I was told that the company would like regularly to be able to give those books to general practitioners—not for them to take home and squirrel away on their book shelves, but because they would be useful in the practice. However, under the pharmaceutical industry's current voluntary code of conduct, it is not permissible to give a medical textbook with a value of $25 to be kept and used in the practice, and perhaps referred to by the practice nurse. That strikes me as slightly bonkers. I hope that the regulations will exclude gifts of that nature, which are intended to benefit the practice rather than the practitioner.

Hilton Dawson: There is another distinction to be made, between pharmaceutical companies, which are well able to look after themselves, and patients.

Philip Hammond: The hon. Gentleman is right. The clause points in two directions: first, towards preventing what I hope are rare instances of manipulation and exploitation of parents, of the kind that we have heard about recently; and secondly, in the direction of the widespread practice of giving small items in the normal course of business not as gifts but as advertising material. The question is of achieving the right balance.
 I sense that we have moved into clause stand part territory, so in anticipation that there may not be a further debate on the clause, I want to mention that generally we support the idea that gifts should be declared. However, that should not be an unnecessarily bureaucratic process designed to catch gifts of very small value or items for use in the practice rather than for the personal benefit of the practitioner. I understand the difficulties in GMS of making that distinction, but I hope that the Minister will manage to do so when making the regulations. 
 In the light of the Minister's remarks, I beg to ask leave to withdraw the amendment. 
 Amendment, by leave, withdrawn. 
 Amendments made: No. 127, in page 17, line 36, leave out `subsection (1)' and insert `the subsection (1A) inserted by section 22'. 
 No. 128, in page 17, line 37, leave out `(1A)' and insert `(1B)'. 
 No. 129, in page 17, line 40, leave out `(1B)' and insert `(1C)'. 
 No. 130, in page 17, line 40, leave out `(1A)' and insert `(1B)'. 
 No. 131, in Clause 24, page 18, line 11, leave out `(g)' and insert `(k)'. 
 No. 132, in, page 18, line 13, leave out `(h)' and insert `(l)'. 
 No. 133, in page 18, line 17, leave out `(3)(h)' and insert `(3)(l)'.—[Mr. Denham.] 
 Clause 24, as amended, ordered to stand part of the Bill.

Clause 25 - Supplementary lists

John Denham: I beg to move amendment No. 98, in page 19, line 1, leave out from beginning to end of line 3.

John Maxton: With this it will be convenient to take Government amendments Nos. 99, 160 and 109 to 112.

John Denham: This clause is about the regulation of practitioners who assist in the provision of primary care services, such as deputies, assistants and locums. They are an essential and sometimes unrecognised part of the primary care work force. It is estimated, for example, that they undertake 20 million consultations each year in general practice. They cover temporary vacancies arising from, for example, sickness, holidays or study leave. However, despite their crucial role, they are largely unsupported and unregulated. A locum can lead an isolated professional life. We want to attend to that gap by integrating them into the range of developing NHS support mechanisms. The list system will enable that.
 I do not want to repeat earlier debates about the list system. Many of the same points that were covered earlier with respect to changes to the main list of GP principals apply also to the present topic. However, I need to make a few quick points. The list, together with provisions for the accreditation of out-of hours-providers, will ensure that GP co-operatives and deputising services, as well as mainstream practices, as it were, will have to employ doctors who are on health authority lists. It may interest the Committee to know that any general practice qualified doctor who works as a locum will be granted access to the NHS pension scheme on admission to the appropriate health authority list. It is our intention, subject to parliamentary approval of the regulations, to backdate the entry to the pension scheme to April 2001. We are discussing with the British Medical Association how that might be done. 
 Amendments Nos. 99, 110, 112 and 160 would provide for a new power of the Secretary of State to make regulations to prevent a person from withdrawing from a health authority principal, supplementary or services list during any period in which he or she was under investigation that might result in removal or suspension from the list. Some unnecessary provisions are also being removed. When considering an application to join a list, the health authority would be obliged to consider the facts underlying any previous decisions by other health authorities to remove the individual from a list. The fact of a previous incident would not, as we have discussed, automatically disqualify a person from admission to a list—unless a national disqualification had been imposed—but the health authority would be entitled to consider it as sufficient grounds for refusing an application. 
 Of course it would sometimes be advantageous for individuals voluntarily to withdraw from a list if they were under investigation or suspension, or had received notice of an intention to remove them—to avoid a health authority-imposed removal, which could rightly disadvantage them in attempts to gain a place on another list. Avoidance of enforced removal would mean that the individual would have nothing to declare to another health authority. That would be an unsatisfactory and inconsistent state of affairs. 
 Amendments Nos. 98, 109 and 111 deal with the fact that in the interests of limiting bureaucracy we do not want to force people who are on a health authority supplementary list to reapply periodically. If there are circumstances that warrant a removal based on elapsed time, for example, because a doctor has not worked as a deputy or assistant for a significant period, they can be prescribed in the regulations that will define the circumstances in which a health authority may remove a person from the list. The provisions are, therefore, unnecessary. I hope that that provides an adequate explanation of the amendment and a brief introduction to the purpose of the clause.

Philip Hammond: In principle, we do not have any problems with the Government amendments. We accept that there is a need to ensure that locum GPs and non-principal GPs are properly covered by all the rules and regulations and are subject to the same kind of scrutiny as principal GPs. When I read the clause, I suspected that the phrase
persons approved by the Health Authority for the purpose of assisting in the provision of general medical services 
might have a precise, technical meaning. However, that meaning is not explicit in the Bill. The lady who makes the tea for the nurse who assists the doctor who delivers the general medical services could be regarded as 
assisting in the provision of general medical services. 
Can the Minister tell me where to find definition of who is and who is not a person 
assisting in the provision of general medical services 
given that cursory glance through the amended 1977 Act has not furnished me with that information? For the moment, I will take it that, as stated, it is clear that the measure applies only to doctors and not to any other employee or any other person who assists in the provision of general medical services. 
 The hon. Member for Isle of Wight and my hon. Friend the Member for New Forest, West (Mr. Swayne) both mentioned nurse-led practices, but the issue extends further than that. More and more of the services that comprise GMS and are provided to patients in the general practitioner's surgery are and will continue to be provided by nurses or persons other than qualified medical practitioners. The Government are encouraging that trend and I expect them to continue to do so, because it makes sensible use of scarce manpower, but it raises the question of why nurses are not to be regulated in a way similar to that in which GPs are to be regulated. 
 There is no doubt that in some places nurses provide services that in other places are provided by employee or principal doctors. Some patients will be treated in a given way by a person who has to be on a list, and others going into a similar surgery in another place will be treated in the same way but by a nurse, who does not have to be on any list. The Minister may be unable to deal with that problem immediately, but he will probably agree that, as the barriers between what medical practitioners and other practitioners do are broken down, there will be a need to do so.

Peter Brand: Returning to an earlier discussion, the hon. Gentleman's point illustrates that, under PMS, the employer must be held accountable. Under GMS, a practice nurse would be accountable for her actions to whoever has the contract—the partner responsible. However, in the circumstances described by the hon. Gentleman, would be no accountability to the practitioners listed under the clause. In fact, there would be no accountability at all.

Philip Hammond: I think that I understand the hon. Gentleman's point. A bizarre situation could arise. Take two people who are, in effect, doing the same job in different practices. One of them is an employee GP in a practice that does not have a large nursing input; the other is a nurse in a forward-looking practice in which nurses perform many of the roles that traditionally have been performed by doctors. The former would have to apply to be put on an approved list by the health authority before he was allowed to do the job, despite having medical qualifications. The latter, despite not having medical qualifications, would not be required to seek any approval to be subject to the procedure for possibly having to provide certificates under the Police Act 1997. The distinction does not seem logical, and it certainly does not seem logical that the medically qualified person has to jump over the hurdles while the non-medically qualified person does not. I hope that the Minister will ponder on that apparent inconsistency and comment on it.
 I also want to test the Minister on short-term locum roles. If a person is on a principal list somewhere and performs a short-term role as a locum elsewhere, will he be required to register again on the supplementary list, or will his inclusion on the principal list be sufficient to give him cover? I am simply trying to think of situations in which the proposals might become cumbersome and unnecessarily bureaucratic. If I have understood the clause correctly, its provisions allow someone, once he has registered with any health authority, to practise as a locum or a person assisting in provision of services in any other health authority area, albeit not across the border between England and Wales. Is there any logical reason for creating that Berlin wall, in the phrase of the former Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson)?

Desmond Swayne: Offa's dyke.

Philip Hammond: That does not quite have the ring of the Berlin wall; I have never heard of anyone tearing down Offa's dyke in recent years. I shall not speculate on that but merely ask the Minister why there is no ability to transfer across the border. I hope that there is a practical reason, and that it is not owing to some post-devolution political correctness.
 The Government amendments are so extensive that, inevitably, one refers to the clause as a whole when speaking to them. I would like to be sure that we are not sanctioning a development that could be used to undermine further the independent contractor status of GMS providers by, for example, requiring their adherence to certain terms and conditions of service. I would like the Minister to assure us that the provisions are designed solely to ensure that people providing assistance are appropriately qualified and are not dodgy characters. I would also like an assurance that the regulations will not create conditionality about being on the supplementary list that will mean greater involvement of the health authority in contractual relationships between the principal and the employee. 
 There is a clear need for such provisions, but a light touch is required to provide a clear set of regulations that do not leave too much room for local discretion and that apply clear criteria across the country. I have to believe that that is the Minister's intention, given that the Bill will allow people registered in the list in one place to practise in another. I look forward to hearing his remarks.

John Denham: The hon. Gentleman raised some interesting questions, which were essentially about whether, as roles develop in primary care, there should be equivalent lists for nurses. It is important to recognise that, at the current point in the evolution of the NHS, individual roles are changing. Nurses are now carrying out procedures, taking responsibility for various treatments and giving advice in surgeries that would previously have been done by GPs. However, formal responsibility for patients and for their care in GMS still rests with the GP. Analogous situations exist in pharmacy. It is professional responsibility that is important, along with the contractual relationship that exists under GMS to provide those services.
 Normal professional regulations are still in place in respect of practice nurses, and although it is legally possible for a patient to be on a GP's list, it is not legally possible to be a nurse's patient, even though it may be the nurse who gives the treatment. That is how the law is structured. It was an interesting speculation, but we are dealing with the responsibilities of practitioners towards their patients. A slightly different situation pertains in PMS, but a nurse-led practice has a different form of accountability because of the PMS contract between the employer or contract holder and the health authority.

Philip Hammond: The Minister sayd that the difference between doctors and nurses is that contractual responsibility under GMS lies with the doctor. Surely the contractual responsibility lies with the principal practitioner and the employee practitioner is in the same contractual relationship to GMS as the nurse employed by the practice—or even the therapist employed by the practice, as many now do.

John Denham: It is true that the principal who holds the list is responsible for the patients. It should be recognised that the locum doctor who steps in for a fortnight while the principal is on holiday is being asked to fulfil the principal's role in a way that the practice nurse is not; that is how the work is normally delegated. There is great concern about the weakness of the checks on locum doctors that I have not heard expressed about the role of practice nurses. We are trying to deal with a genuine problem. One of the advantages of having a list of locums is that it does not take from principal GPs the responsibility to assure themselves of the suitability of a locum, but provides a framework within which the appraisal of locums can take place.

Peter Brand: I should be grateful if the Minister could solve a conundrum. If someone who wants to work as a locum for a PMS project have to be on a list, or does an individual contractual arrangement have to be entered into every time someone wants to work for a PMS set up?

John Denham: Those who want to work as a locum will be required to appear on either a PMS list or a supplementary list. Under the Bill's provisions, it will not be possible for anyone to provide NHS services unless they are on the appropriate list. That brings me to the point raised by the hon. Member for Runnymede and Weybridge about principals on the medical list seeking to act as locums. The Bill provides that a principal on the medical list would be able to act as a locum in another health authority.

Peter Brand: I should like to return to the PMS question, about which I am still unclear. I presume that, in a nurse-led PMS contract, the doctor employed by a nurse would have to be accountable by being on a list, but that the nurse employed by a practice nurse would not. There is no accountability between the practice nurse and practice doctor, so the practice doctor cannot have any responsibility for the actions of the practice nurse under the PMS scheme. Does that not leave the practice doctor vulnerable and the practice nurse controlled only through her employer?

John Denham: The doctor still has to exercise his professional responsibilities under those circumstances. I may be missing the hon. Gentleman's point—

Peter Brand: If the Minister will allow me—

John Denham: If the hon. Gentleman will let me get two words out before he leaps to his feet, it may be best if he made another speech on the subject. To be perfectly honest, we have been through the matter several times already and I am struggling to understand the hon. Gentleman's difficulties. I would prefer a clearer exposition that I have heard so far in the hon. Gentleman's brief interventions.
 The hon. Member for Runnymede and Weybridge sought an assurance, as he always does, that we are not proposing some Machiavellian back-door way of doing away with independent contractor status—

Philip Hammond: It is eroding.

John Denham: No, it is about establishing a better framework for ensuring that doctors, particularly locums, are properly regulated and supported. The list means that for the first time we can develop a proper system of appraisal for locum doctors akin to the system that applies to GPs. That has never existed before and amounts to one of the greatest single gains from our proposals.

Peter Brand: The Liberal Democrats welcome the idea of bringing locums out from the cold and into a regulatory framework, but let me have a final go at explaining my difficulty with developments under PMS. When a PMS project is led by a person who is not on a list—it could be any employer—the doctor will have to work to directions, so it is the employer who determines the patterns of work. The employer will decide what activity is to be performed by doctors and what by nurses. If the doctor has no control over how the work is shared out within the PMS project, people who are not on any list will be carrying out duties usually done under the supervision or control of people who are on a list, such as principals. The professional doctor may have no control over activities for which he may be held accountable by a controlling authority. I am sorry if that is complex, but surely the Minister can understand that explanation, however inadequate, of my real anxieties.

John Denham: I am struggling a little. The hon. Gentleman is presenting a caricature of nurse-led PMS contracts and conjuring up an anti-nurse-led PMS contract vision of dictatorial nurses forcing GPs not to follow their usual professional responsibilities—
Dr Brand rose—

John Denham: Let me pursue this line of argument. Consistent with the hon. Gentleman's argument, it would be impossible for hospital doctors to carry out their responsibilities because they are employed by another organisation. I do not accept that. Under PMS, irrespective of whether doctors are the contract holder with the health authority, they are responsible for their patients. Nothing overrules that. We are simply ensuring that all PMS doctors are on a list. At present, unless they are principals, they are not.

Peter Brand: I hear the Minister's explanation, but hospital doctors are not on a supplementary list. They are accountable to their employing authority, the hospital, as are other practitioners within the team. I do not have an anti-nurse-led PMS worry, but a worry about PMS itself. That is why I developed the point about corporations running PMS services. Either accountability stops with the practitioner on the definitive or supplementary list, or the employer must become more directly accountable—in the same way as practitioners. The solution is to put either practitioners or the employing authority on a list.

John Denham: The hon. Gentleman is completely missing the point. Previously, he asked whether commercial companies would be allowed to provide a service in the same way as corporate dental bodies. I said no, that is not happening, but it does not follow that there is no accountability. The health authority has a contract with a nurse-led practice, which provides the line of accountability. It is a different issue from ensuring that all the health service practitioners covered in part II are on a list.

Philip Hammond: First, the Minister did not deal with the split between England and Wales. Secondly, throughout his remarks he referred to locums. I assume that the hon. Gentleman uses the term as a short hand because GP registrars and anyone either training or employed in general practice as a doctor will also be covered by the regulations. It irritates GP registrars enormously when patients refer to them wrongly as locums.

John Denham: The hon. Gentleman is right. I have used the term as a short hand for a larger group of non-principals. The term ``assistant'' is defined in the GMS regulations, where other definitions are also set out. The Welsh Assembly passes Welsh regulations made under the 1977 Act, so the lists are different.
 Amendment agreed to. 
 Sitting suspended. 
 On resuming—

John Denham: I beg to move amendment No. 134, in page 19, line 8, leave out `by health Authorities'.

John Maxton: With this we will consider Government amendment Nos. 163 and 166.

John Denham: I can assure the Committee that this and the remaining Government amendments to the clause are essentially technical and consequential.
 Amendment agreed to. 
 Amendment made: No. 99, in page 19, line 20, at end insert— 
`( ) circumstances in which a person included in a supplementary list may not withdraw from it,'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 135, in page 19, line 33, leave out `49K(1)' and insert `49K'.

John Maxton: With this we will take Government amendments Nos. 136, 100 to 103, 147, 105 to 108, 164, 165 and 167.

John Denham: These are simply technical and drafting amendments.
 Amendment agreed to. 
 Amendment made, No. 136, in page 19, line 49, leave out `8A' and insert `8ZA'—[Mr. Denham.] 
 Clause 25, as amended, ordered to stand part of the Bill.

Clause 26 - Suspension and disqualification of practitioners

Amendments made: No. 100, in page 20, line 10, leave out `section 19 of'. 
 No. 101, in page 20, line 19, after `practitioners' insert `and dental corporations'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 137, in page 21, line 2, leave out `49M' and insert `49MA'.

John Maxton: With this it will be convenient to take Government amendment No. 162.

John Denham: The provisions of amendment No. 162 will prevent a practitioner who has been disqualified from a health board list by an NHS tribunal in Scotland or Northern Ireland from being included on any list in England or Wales. Specifically, it enables the Secretary of State to make provisions in regulations to recognise the decisions of Scottish and Northern Irish tribunals in England and Wales. It is essential to ensure that there are robust arrangements across the UK so that practitioners removed from lists in one area of the country do not appear in another area. Contractors who are unfit to practice in Scotland or Northern Ireland are likely to be unfit to practice in England or Wales. Indeed the FHSAA will not be able to overturn or review a decision of a Scottish or Northern Irish tribunal. I am sure that everyone will agree that this is an important provision to ensure patient safety. Amendment 137 makes a consequential change to the numerical reference in the clause to reflect the addition of the new section.

Desmond Swayne: I could have dealt with this point in an intervention, but I failed to catch the Minister's eye. I was wondering about the degree of discretion that the amendment appears to give the Secretary of State. I refer specifically to the phrase in parentheses and ``whether or not exactly'' the two things may correspond to what has happened in a health board in Scotland, for example, as against the circumstances in England. Can the Minister give an example to bring that to life so that we can understand precisely what is meant?

John Denham: I believe, and I will certainly write to the hon. Gentleman if I am wrong, that because the tests that we are introducing on suitability, efficiency and fraud into the English legislation do not mirror directly the tests applied by the NHS tribunals in Scotland and Wales, which currently have the test of efficiency, they do not map on to each other directly. It will be necessary to allow one to be translated into the other to achieve the same effect.
 Amendment agreed to.

John Denham: I beg to move amendment No. 138, in page 21, line 23, leave out from `they' to `with' in line 26 and insert
`so decide, they must impose such conditions as they may decide on his inclusion in the list'.

John Maxton: With this it will be convenient to take Government amendments Nos. 139 to 141 and 150.

John Denham: This group of technical amendments clarifies the provisions of the Bill in relation to the health authority's power to make a contingent removal from its main practitioner list when dealing with inefficiency or fraud. The most substantial changes are made by amendments Nos. 138 and 139, but they essentially clarify the policy intention rather than change direction or add a new function. Amendment No. 138 makes it clear that if a health authority makes a contingent removal it must apply conditions on the practitioner with a view to removing any prejudice to the efficiency of the NHS or preventing further fraud. Essentially, if one limits a person's scope to practise because of a particular problem, one must limit it in a way that deals with the problem.
 Amendment No. 139 clarifies that where a practitioner fails to meet any such conditions, a health authority can vary them, apply new ones, or remove the practitioner from the list. Amendment No. 150 is a consequential drafting amendment. Amendments Nos. 140 and 141 are technical amendments to ensure clarity of the powers in the clause. I hope that that is sufficient for the Committee.

Philip Hammond: I have a brief question. The Minister used the word ``contingently''. This may not be the place to ask, but could he tell me the difference between ``contingently'' and ``conditionally''? It seems a rather nice distinction.

John Denham: I have a helpful note from my officials somewhere in my notes explaining that difference, but I will have to rely on my memory. Conditional has the sense that a practitioner should fulfil certain conditions, whereas contingent essentially means that he should not do certain things. I think that that is the underlying difference. Clearly it does not make sense to say that it will be conditional on someone who has been found guilty of fraud not to handle money. That would be an odd use of the English language; instead, it would be contingent on them not handling money. That is the difference in the English language. I bow to the superior wisdom of parliamentary counsel that this is the correct way of doing it.

Philip Hammond: For the record, the Minister did that without the benefit of any notes, and we are all terribly impressed, but why did parliamentary counsel not have a look at the dictionary when drafting the original Bill?
 Amendment agreed to. 
 Amendments made: No. 139, in page 21, line 30, at end insert— 
 `(3A) If the Health Authority determine that the practitioner has failed to comply with a condition, they may decide to— 
 (a) vary the conditions, or impose different conditions, or 
 (b) remove him from their list.'.
 No. 140, in page 21, line 31, after `may' insert `decide to'. 
 No.141, in page 21, line 38, after `49G' insert 
`(other than in circumstances falling within paragraph (b))'.
 No.102, in page 21, line 40, leave out `Council' and insert `body'.—[Mr. John Denham.]

John Denham: I beg to move amendment No.142, in page 22, line 5, after `case' insert—`(a)''.

John Maxton: With this it will be convenient to take Government amendment Nos. 143 and 144.

John Denham: The provisions in new section 49H in the Act provide that a health authority may suspend a practitioner while it decides whether he should be removed or contingently removed from a list. In such cases the health authority must specify the period. If the period has expired, amendment No. 143 enables the health authority to continue the suspension for a further specified period.
 We do not propose the suspension of family health service contractors to continue indefinitely. We have no desire to recreate in the family health services some of the problems that have been encountered, for example, with the suspension of consultants in hospital services, which we are as Government anxious to deal with. It is in everyone's interest to ensure that the period of suspension is kept to a minimum, but there are cases in which it will be necessary to extend an initial period of suspension while further enquiries are made or a regulatory body considers the case. 
 Contractors need to be protected from the uncertainty of indefinite suspension. Amendment No. 144 clarifies that if a health authority imposes an initial period of suspension which is running out and then imposes a further period of suspension, the total period of suspension, including the initial period, may not normally exceed the six months set out in the Bill. If a health authority wishes to continue a suspension beyond six months it will be required to make representations to the appeal authority, just as it would have done had it made an initial suspension for a six-month period 
 Amendment agreed to. 
 Amendments made: No. 143, in page 22, line 7, at end insert 
(b) if that period has expired, they may impose a further suspension, for a period which they must specify.'.
 No.144, in page 22, line 9, after `case)' insert `, 
including in both cases the period of any further suspension imposed under subsection(4)(b),'.
 No.103 in page 22, line 28, leave out `(4)' and insert `(6)'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 145 in page 22, line 37, after `and' insert `(except in prescribed cases.)'.

John Maxton: With this it will be convenient to take Government amendments Nos. 146, 148, 104 and 149.

John Denham: Amendment Nos. 145, 148 and 149 clarify the circumstances in which a health authority may or must carry out a review of contingent removal or suspension and the decisions they are able to reach as a result of the review. Amendment No. 146 prevents a health authority from being able to review—

Desmond Swayne: Can the Minister explain what `except in prescribed cases' refers to? Presumably it is the same prescribed cases as are in subsection 5A but could he just explain what those might be?

John Denham: Amendment No. 146 prevents a health authority from reviewing a decision of the appeal authority to impose a contingent removal or suspension on a practitioner. It would be wholly inappropriate for a lower level body, the health authority, to be able change the decision of a higher level body, the appeal authority, hence the reference to ``except in prescribed circumstances'' in relation to a health authority's ability to review a decision. That is what is inserted by amendment No. 145. Amendment No. 104 removes the provision for a health authority to be able to shorten a period of suspension on review.
 Amendment agreed to. 
 Amendments made: No. 146, in page 22, line 39, after 'than' insert 
`a contingent removal or a suspension imposed by, or'.
 No. 147, in page 22, line 44, leave out `conditionally' and insert `contingently'. 
 No. 148, in page 22, line 46, at end insert— 
`( ) confirm the contingent removal or the suspension,'.
 No. 104, in page 22, line 47, leave out 'or shorten its period'. 
 No. 105, in page 23, line 1, leave out `conditional' and insert `contingent'. 
 No. 149, in page 23, line 2, after `conditions,' insert `impose different conditions,'. 
 No. 106, in page 23, line 2, leave out `conditional' and insert `contingent'.—[Mr. Denham.]

Desmond Swayne: I beg to move amendment No. 179, in page 23, line 7, leave out `21' and insert `28'.
 The amendment would extend the time by seven days in which a general practitioner has the right of appeal to the Family Health Service Appeals Authority. The provision of an extra week is consistent with the period for an appeal to the General Medical Council. We regard those two appeal procedures as similar in their consequences for the practitioner if he were delisted. If his accreditation were removed by the health authority, it would be a career-threatening move. Therefore, we think it consistent to equalise the time period.

John Denham: We agree with the thrust of the amendment, for the reasons given. However, we have examined the drafting and found it flawed. If the hon. Gentleman withdraws the amendment, we will introduce amendments on Report.

Philip Hammond: Will the Minister explain what is wrong with our amendment, as it simply changes the number 21 to 28? The Government may find it disagreeable to accept Opposition amendments, but the Minister is being a bit ingenuous in suggesting that we withdraw our 28 so that he can introduce his 28 on Report.

John Denham: If he wishes, the hon. Gentleman is welcome to take up Opposition time on Report in moving the necessary consequential amendment required on page 23, line 22 to proposed section 49J)(5)(a). However, I offer to use Government time on Report for that purpose.

Philip Hammond: It was a perfectly simple question and, as it turned out, it has a relatively simple answer. I simply wanted to ascertain that the Minister was not simply being churlish in refusing to accept the Opposition amendment.

Desmond Swayne: I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn. 
 Amendments made: No. 150, in page 23, line 11, after `49F' insert `or 49G(3A)'. 
 No. 107, in page 23, line 12, leave out `conditionally' and insert `contingently'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 151, in page 23, line 14, after '49G' insert
`, or to vary any condition or to impose any different condition under that section'.

John Maxton: With this it will be convenient to discuss the following amendments: No. 180, in page 23, line 14, after '49G', insert
', or to vary the terms of service of the person concerned for the purpose of or in connection with the imposition of any such conditions.'.
 Government amendments Nos. 152 to 154 and 161.

John Denham: The amendments deal with contingent removals and appeals to the Family Health Service Appeals Authority; they clarify the precise nature of the practitioner's appeal rights. Amendment No. 151 makes it clear that a practitioner can appeal to the FHSAA, against not only the health authority's original decision contingently to remove him but any further health authority decision to vary or change the conditions imposed on the practitioner in pursuance of a contingent removal.
 Amendment No. 180, tabled in the names of the hon. Members for Woodspring and for Runnymede and Weybridge, and Government amendment No. 152 are designed clarify that a practitioner would have the right to appeal to the FHSAA against any health authority decision to vary his terms of service in pursuance of a contingent removal. That is an essential safeguard, so I am pleased that it has support from both sides of the Committee. I propose that amendment No. 152 is accepted, which I hope will meet the Opposition's concerns. 
 Amendments Nos. 153 and 161 clarify the position on the rights of appeal. As we have already discussed, the policy intention is that there should be no right of appeal against the decision to suspend. That will be a statutory, time-limited, neutral act, and we want efforts to be focused on addressing concerns and not on legal process. A right of appeal will be available against a decision to remove or contingently remove. The amendments tighten the drafting of the clause, so that it cannot be read in a way that infers a right to appeal against a decision to suspend. 
 Amendment 154 provides for the practitioner or health authority concerned to apply to the FHSAA for the conditions of a contingent removal imposed by that body to be varied, replaced or revoked.

Desmond Swayne: I acknowledge that the purpose of amendment No. 180 is achieved by Government amendment No. 152. Before I ask leave to withdraw the amendment, I want to put it in on the record that we tabled our amendment first.

John Maxton: Order. The only amendment moved in a group is the first on the list. The hon. Gentleman's amendment was not moved.
 Amendment agreed to. 
 Amendments made: No. 152, page 23, line 14, at end insert— 
`( ) to vary his terms of service (under section 49G(4)),'.
 No. 153, in page 23, line 15 after `review' insert `of a contingent removal'. 
 No. 154, page 23, line 19, at end insert— 
 `( ) If the FHSAA decides to remove the practitioner contingently, the Health Authority and the practitioner may each apply to the FHSAA for the conditions imposed on the practitioner to be varied, for different conditions to be imposed, or for the contingent removal to be revoked.'.
 No. 108, in page 23, line 21, leave out `conditional' and insert `contingent'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 155, in page 23, line 31, leave out `and'.

John Maxton: With this we may take Government amendments Nos. 156 and 157.

John Denham: In new section 49K in clause 26, there is already provision for the appeals authority to decide to nationally disqualify a practitioner from the principal and supplementary lists of all health authorities; it was referred to earlier as national disqualification. However, in the Bill as drafted there is no reference to national disqualification from the PMS or PDS lists, which we shall discuss in clause 27. Amendment No. 157 inserts a reference to those services lists that correct that anomaly and therefore enables the FHSAA to disqualify a practitioner from all lists. Amendment No. 155 is a consequential amendment that corrects the grammar and amendment No. 156 is similarly a drafting amendment.
 Amendment agreed to. 
 Amendments made: No. 156, in page 23, line 32, leave out `practitioners' and insert `individuals.' 
 No. 157, in page 23, line 34, at end insert— 
`and 
 ( ) any services list of individuals of the practitioner's description prepared by any Health Authority under section 28DA above or under section 8ZA of the National Health Service (Primary Care) Act 1997, 
 or any such list (or lists) of a description (or descriptions) specified by the FHSAA in its decision'.—[Mr. Denham.]

John Denham: I beg to move amendment No. 158, in page 24, line 4, leave out from beginning to end of line 7.
 Subsection 49K(5) provides that if following an appeal by a practitioner the appeals authority decides to revoke its decision nationally to disqualify that practitioner, the FHSAA must also confirm or revoke the original health authority decision to move the practitioner from its list or to substitute a contingent removal. There is no reason to revoke the original decision and the amendment therefore deletes the unnecessary wording. 
 Amendment agreed to.

Peter Brand: I beg to move amendment No. 32, in page 24, line 8, leave out `may' and insert `shall'.

John Maxton: With this we may take Government amendment No. 159 and amendment No. 33, in page 24, line 9, after `profession', insert
`and all other Health Authorities'.

Peter Brand: I apologise to the Committee as the amendment seems to have gained something in translation. It should have read—I realise it makes the amendment slightly incompetent—
delete `or in prescribed cases may'. 
I am anxious that even using all the safeguards built into the clause, it may take up to six months before a suspension is resolved. It would be against natural justice if that practitioner does not continue to receive remuneration in that time. I should be grateful if the Minister would explain in what prescribed cases the payments were not to be made.

John Denham: I listened with care to what the hon. Member for Isle of Wight said and to the questions he asked, but I thought that his amendment was about something entirely different. I shall deal with my interpretation of what it would do, and I shall briefly talk about the question that he has raised, which will save us dealing with it in the stand part debate.
 The issue that I thought we were dealing with is that of notification of health authority decisions to remove and suspend practitioners from their main list. It is obviously important, in the system that we are setting up, that robust mechanisms are in place to inform all health authorities of the removal or suspension of practitioners, so that people cannot be moved from one list simply to re-enter the NHS in another part of the country without anyone knowing anything about it. 
 We intend to put in place a comprehensive alert letter system ensuring that health authorities, regulatory bodies and the Department of Health are fully appraised of the removal and suspension of primary care practitioners. We also intend—and this is what I understood to be the import of the amendment—to introduce regulations to underpin an alert letter system. The provision in amendment No. 159 will go further than that proposed in amendment No. 32 in ensuring that all relevant bodies are properly informed of these key decisions. 
 The hon. Gentleman raised an important issue, which we may be able to debate at greater length on stand part. Provision will be made to protect the financial position of a suspended principal or a member--for example a GP--of the practice. We will also need to make provision for locums who are under suspension, which will require a different route to be constructed because clearly they are not directly on a payroll—if I can use that expression. 
 The importance of appropriately protecting the financial position of somebody who has been suspended has been recognised, and I can reassure the hon. Gentleman on that point. I am sure that these amendments are not the place to discuss the matter in detail.

Peter Brand: I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdraw. 
 Amendments made: No. 159, in page 24, line 9, leave out 
`the body which regulates the practitioner's profession' and insert `prescribed persons, or persons of prescribed descriptions,' 
No. 160, in page 24, line 10, at end insert— 
`Withdrawal from lists 
 . Regulations may provide for circumstances in which a practitioner— 
 (a) whom a Health Authority are investigating in order to see whether there are grounds for exercising their powers under section 49F, 49G or 49H, or 
 (b) who has been suspended under section 49H, 
 may not withdraw from a list in which he is included.'.
 No. 161, in page 24, leave out line 22 and insert 
`any right of appeal which he may have'.
 No. 162, in page 24, line 25, at end insert— 
 `Corresponding provision in Scotland and Northern Ireland 
 49MA.—(1) This section applies where it appears to the Secretary of State that there is provision in Scotland or Northern Ireland under which a person corresponding to a practitioner may be dealt with in any way which corresponds (whether or not exactly) with a way in which a practitioner may be dealt with under this group of sections. 
 (2) A decision in Scotland or Northern Ireland to deal with such a person in such a way is referred to in this section as a ``corresponding decision''.
 (3) If this section applies, the Secretary of State may make regulations providing for the effect to be given in England and Wales to a corresponding decision. 
 (4) That effect need not be the same as the effect of the decision in the place where it was made. 
 (5) The regulations may not provide for a corresponding decision to be reviewed or revoked in England and Wales.'.—[Mr. Denham.]
 Clause 26, as amended, ordered to stand part of the Bill.

Clause 27 - PMS and PDS lists

Amendments made: No. 109, in page 25, line 10, leave out from beginning to end of line 11 
 No. 163, in page 25, line 16, leave out `by Health Authorities'. 
 No. 110, in page 25, line 28, at end insert— 
`( ) circumstances in which a person included in a services list may not withdraw from it,'.
 No. 164, in page 26, line 3, leave out `49K(1)' and insert `49K'—[Mr. Denham.]

Desmond Swayne: I beg to move amendment No. 182, in page 26, line 9, at end insert—
 `(7) Before making regulations by virtue of this section, the Secretary of State must consult such organisations as he thinks fit appearing to him to represent medical practitioners providing general medical services or dental practitioners providing general dental services, as the case may be.'.

John Maxton: With this it will be convenient to take amendment No. 183, in page 27, line 37, at end insert—
 `(7) Before making regulations by virtue of this section, the Secretary of State must consult such organisations as he thinks fit appearing to him to represent medical practitioners providing general medical services or dental practitioners providing general dental services, as the case may be.'.

Desmond Swayne: The purpose of clause 27 is to extend the health authority lists to personal medical services to mirror the provisions in clause 24 with respect to general medical services. There is, however, a key difference between the two clauses in that under clause 24, the Secretary of State is required to
consult such organisations as he thinks fit appearing to him to represent medical practitioners providing general medical services. 
In effect, that means the general practitioners committee of the BMA. He has to make that consultation before he makes the regulations. 
 In clause 27, there is an omission with respect to the regulations being made for personal medical services, in that there is no requirement to consult in the same way. What is sauce for the goose should be sauce for the gander. We have lifted the wording of our amendments directly from the provision in clause 24. Members of the Committee may have spotted that, so eager were we to use the exact words of the Bill, we left a small inconsistency in the wording of the amendment—a drafting error—in that it refers to ``general medical services'', when, to be pertinent to the clause, it should refer to ``personal medical services. However, the principle is sound. 
 If PMS general practitioners are to have confidence in the system, it is essential for them to have the same rights and protection nationally as their general medical services colleagues. That principle should also extend to other medical practitioners, such as dentists, who provide personal medical services. 
 The BMA's general practitioner committee must apply itself equally to GMS and PMS issues. The BMA states: 
 This is a matter of fundamental importance to the BMA. 
It is happy for the Government to consult others, either informally or through the Department of Health's personal medical services implementation group, but not as a substitute for negotiation with the BMA's GP committee, which is the sole recognised body for negotiating on the rights of general practitioners. That recognition predates the arrival of personal medical services. 
 A lack of national consultation and similar rights to those enjoyed by general medical services practitioners will cause alarm and may influence general practitioners in their stance on personal medical services. At a time when constructive co-operation is at a premium and co-operative dialogue is in everyone's interests, it is essential to minimise suspicion about personal medical services and the introduction of the clause. 
 Personal medical services seem increasingly to have a national dimension. The third wave and all future waves of personal medical services contracts will operate within a nationally specified core contractual framework. Paragraph 8.9 of the NHS plan states: 
 By 2004 both local Personal Medical Services and national arrangements are set to operate within a single contractual framework that will meet the key principles and requirements of a modern NHS. 
We believe that the same negotiating framework and requirement for the Secretary of State to consult before making regulations should apply equally to PMS and GMS. Does it? A suspicion will remain if the Government do not reassure us in that respect. Is the intention to use the roll-out of PMS as a vehicle to weaken existing consultation methods with the medical profession?

John Denham: One of the delicious ironies of serving on the Committee at this moment in history is that the casual visitor from Mars might have difficulty in identifying which Front-Bench spokesman was the product of the party of closed shops, trade union power and overbearing centralisation, and which was the representative of the radical, libertarian, free-market right.
 We have taken the unusual step of referring in the Bill to consultation with the BMA for the purposes of the clause. I can tell the hon. Member for Runnymede and Weybridge that that is not without precedent, because there is a similar measure in the 1999 Act, although it is unusual. The issue is one of great sensitivity among members of the profession, so we want to consult them, and that is recognised in the Bill. We intend to mirror, for PMS, the regulations across the different lists. It would not be satisfactory for GPs to have a different set of criteria on which to be judged unsuitable or for a different process to be in place. 
 There is a wider issue. A distinction must be drawn between the common or garden use of the term ``to consult'', which means seek the views of or hear the opinions of, and the formal definition for negotiating purposes, which is what the amendments would bestow. 
 Our view is that PMS is a voluntary, local contract, entered into by GPs at local level. It is perfectly appropriate for GPs who are considering doing that to be represented by the BMA through the local medical committee. Indeed, during the passage of the previous Act, we changed the legislation to enable PMS GPs to be members of the local medical committee and to be represented by them. Because of the voluntary nature of that contract, it would not be right for us to agree a framework in which the general practitioners committee nationally could determine the contract that someone could enter into at local level through his formal negotiating rights. 
 That said, we are anxious to work with the BMA and a range of other organisations for the successful development of PMS. We have set up a PMS implementation group.

Doug Naysmith: I share the Minister's delight in hearing the hon. Member for New Forest, West arguing for what amounts to trade union negotiating rights. That is almost unprecedented in the House. I take everything that the Minister has said. It is important that people do not get the message that PMS is in any way second-rate compared with GMS. The Minister is sending the message that PMS is important to the 10-year plan for the NHS.

John Denham: The fact that 22 per cent. of GPs have opted to work on PMS pilots suggests that the more flexible way of working, under which remuneration much more closely reflects the clinical quality of patient service than in the GMS contract, is attractive to them.
 The BMA rightly has formal negotiating powers on the national contract, and we are seeking to agree a new contract with more emphasis on quality and outcomes. PMS is enabling innovative GPs throughout the country to find new ways of working and providing services that are popular with their patients. I have given assurances about the effect of the amendments on the regulations. We want uniformity across the list, and the Bill provides for consultation on GMS. I ask the Committee to resist the amendments.

Peter Brand: I listened carefully to what the Minister said, and I was thinking particularly about an earlier commitment that he made. He said that PMS was a voluntary arrangement and there would always be the opportunity to opt out of it and return to GMS. Can we have an assurance from the Minister that should that option no longer exist—and I believe that it could be extinguished without primary legislation—he will not extinguish the option of either staying in or returning to GMS without bringing in the necessary consultation powers, which are not unreasonable, proposed by the hon. Member for New Forest, West?

John Denham: The hon. Gentleman has made a fair point. There is a stage at which PMS pilots may become permanent in the future, and that is set out in the Bill. I would need to refer back to the 1977 Act to see whether it has the consequential effect of eliminating the possibility of removing GMS. I will look at that issue and write to the hon. Gentleman.

Desmond Swayne: I accept what the Minister says about having taken the unusual step of putting the requirement to consult in the Bill. He has done that in 24 in respect of general medical services, but not respect of personal medical services. Precisely that omission gives rise to the suspicion that has always existed about the Government's motives for PMS.
 I can understand the Minister saying that a different kind of negotiation and consultation would be appropriate for PMS, although I disagree—for precisely the reasons that I set out in respect of the national infrastructure to which the national plan refers. I can understand the Minster deciding that the consultation on PMS should be different from the consultation in clause 24, but clause 27 contains no requirement for consultation. If the Minister has ideas about a different type of consultation before the regulations are made, perhaps he should have put something in the Bill. We have not found what the Minister has said reassuring, but because of the drafting errors in our own amendments, we will not press them. However, I give notice that we will seek to return to the matter on Report. I beg to ask leave to withdraw the amendment. 
 Amendment, by leave, withdrawn. 
 Amendments made: No. 165 in page 26, line 12, leave out `8A' and insert `8ZA' 
 No. 111, in page 26, line 40, leave out from beginning to end of line 41. 
 No. 166, in page 26, line 46, leave out `by Health Authorities'. 
 No. 112, in page 27, line 9, at end insert— 
`( ) circumstances in which a person included in a services list may not withdraw from it,'
 No. 167, in page 27, line 31, leave out `49k(1)' and insert `49k'.—[Mr. Denham]. 
 Clause 27, as amended, ordered to stand part of the Bill.

Clause 28 - The Family Health Services appeal authority

Philip Hammond: I beg to move amendment No. 185, in page 28, line 32, at end
 insert— 
`(aa) medical practitioner providing personal medical services.'.

John Maxton: With this it will be convenient to take amendment no. 186, in page 28, line 34, at end insert—
`(cc) dental practitioner providing personal dental services.'.

Philip Hammond: Clause 28 establishes the Family Health Services Appeal Authority as an independent body, whereas it is currently set up as a special health authority. Most of the issues surrounding this provision would be best dealt with in a short clause stand part debate, so I shall focus my remarks narrowly on the amendments.
 Amendments Nos. 185 and 186 seek to insert into the new schedule 9A to the 1977 Act two additional classes of member that must be included—a medical practitioner providing personal medical services and a dental practitioner providing personal dental services. Much of what my hon. Friend the Member for New Forest, West said in the previous debate is applicable again here. Whether we like it or not, it is clear that personal medical services will represent a growing share of family practitioner services. It seems rather inappropriate that the FHSAA that will be dealing with appeals in respect of GMS and PMS providers should have a statutory inclusion of a GMS or GDS provider, but no statutory inclusion of a PMS or PDS provider. We would all be wary of creating an unwieldy body. 
 Amendment No. 34, which we will discuss next, connects with the discussion because it deals with the overall size of a body if a percentage of its membership were laypeople. There is no robust reason for having statutory GMS and GBS representation but no statutory PMS and PDS representation. If, as the hon. Member for Bristol, North-West (Dr. Naysmith) said, that is not to send out the signal that PMS and PDS are somehow inferior cousins, the Minister must explain why those organisations are not to be represented on the FHSAA.

John Denham: There is no good reason why they should not be, and we will address that in amendments tabled on Report.
 Members of the Committee who have noticed that there are fewer Government amendments to the clause than to earlier ones may have drawn the erroneous conclusion that that part of the Bill was almost perfect. As I said in my letter to members of the Committee a few days ago, amendments will be brought forward on Report and some will address the issue raised by the hon. Gentleman. I will give my best indication of the other areas that need further attention in the stand part debate.

Philip Hammond: As ever, I am grateful to the Minister for that indication. It is always nicer when he accepts our amendments, but I know that he specialises in giving credits on Report so we will live with that as a second best option. I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn.

Peter Brand: I beg to move amendment No. 34, in page 28, line 39, at end insert
`such number being equivalent to at least fifty per cent of the total membership of the FHSAA'.
 The spirit of the amendment is the same as that of the amendments to the previous group. I am always slightly worried about setting out such prescriptions as specifying that a body must comprise six members but not specifying the size of an overall body. We could, for example, have a tribunal of seven—consisting of one layperson, one legally qualified chairman and five professionals—or a body of 40, but neither option would be satisfactory. Our probing amendment would require an appropriate lay input, which we consider should be slightly more than 50 per cent. because the body represents patients' interests. A reasonable solution would be to have 50 per cent. lay and 50 per cent. professional membership, with a lay legally qualified chairman.

Philip Hammond: Does the hon. Gentleman mean lay members in the everyday sense or simply people who are not providing medical, ophthalmic, dental or pharmaceutical services? Given that the Lord Chancellor will appoint the body, it is possible that along with doctors, ophthalmologists, dentists and pharmacists, a smattering of lawyers could be involved.

Peter Brand: If the Lord Chancellor is involved, they might all be lawyers. Under the definition that we are discussing, the members would be lay. I hope that the Minister will come back to that issue on Report because it would be unsatisfactory not to get a flavour of the tribunal and know, for example, whether it will represent patient groups or interests.

John Denham: We shall certainly consider the amendment in drawing up those to table on Report. Because the measure is established under the legislation on tribunals, the Lord Chancellor—rather than us—will determine some of the key issues. We expect that a hearing, which is perhaps the critical part of the exercise, would typically consist of a panel of three members: a legal chair, a lay member and a medical member. As I understand it, the amendment is concerned with the size of membership from which such panels can be drawn. In drafting amendments on Report, we will want to consider the appropriate size for a workable body. Strong lay representation will certainly be required because there is a strong lay element in those panels that will undertake hearings.

Philip Hammond: The Minister referred to legislation on tribunals under which the tribunal will be established. I wonder whether he could clarify that statement, because my understanding is that the tribunal will be established by this clause, not by reference to any other legislation on tribunals.

John Denham: That is right. However, it will be supervised by the Council on Tribunals. The tribunal will be distinct from bodies—special health authorities, for example—in which the Secretary of State has an involvement, in that the Lord Chancellor will play a part in proceedings. If the hon. Gentleman wants legal chapter and verse, it might be necessary to come back to him on Report, but suffice it to say that the distinction to which I have referred is an important one.

Philip Hammond: The Minister has told us that, in effect, the tribunal will be governed by procedures laid down by the Council on Tribunals. I am not familiar with that body, and nothing in the Bill suggests that the tribunal and its practices will be subject to regulation by such a body. How are we to understand the relationship between the FHSAA and the Council on Tribunals?

John Denham: I probably need to come back to the hon. Gentleman in due course, so that I can ensure that I get the description and legal requirements absolutely right. However, I should point out that we want the authority to be reconstituted with members appointed by the Lord Chancellor, rather than the Secretary of State. That is one of the guarantees of independence that we are seeking to establish. The Lord Chancellor, in consultation with the Secretary of State, will also determine proposals for the constitution of the authority.
 The hon. Gentleman asked further questions about the legal basis, and I have been advised just in the nick of time that the FHSAA will be a tribunal according to the terms of the Tribunals and Inquiries Act 1992. Under the provisions in this Bill, the Lord Chancellor will make the rules.

Philip Hammond: I am not seeking to be difficult, but given that the FHSAA is not actually called a tribunal, and given that the clause does not state that the FHSAA shall be a tribunal according to the 1992 Act, how will statutory effect be given to its status as a tribunal? If the Minister does not want to answer that question now, perhaps he might do so during the stand part debate.

John Denham: I am familiar with this important point, but given that my notes do not assist me in that regard, it would probably be more useful for me to write to the hon. Gentleman and other members of the Committee, setting out the relationship between the FHSAA and the 1992 Act.

Peter Brand: I would value your guidance, Mr. Maxton, as to whether we will have a stand part debate.

John Maxton: There is no reason why we should not.

Peter Brand: I am happy, therefore, to let the matter rest for the time being and return to it on Report. I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn.

John Denham: I beg to move amendment No. 113, in page 29, line 10, at end insert—
 `( ) In the National Health Service (Primary Care) Act 1997—
(a) in section 22 (supplementary regulations about personal medical or dental services), in the section 28E to be inserted into the 1977 Act, in subsection (7)(e), for ``Tribunal constituted under section 46'' there shall be substituted ``Family Health Services Appeal Authority constituted under section 49N''; and
(b) in Schedule 1 (preferential treatment on transferring to medical lists), in paragraph 9(a), for ``Tribunal constituted under section 46'' there shall be substituted ``Family Health Services Appeal Authority constituted under section 49N''.'.

John Maxton: With this it will be convenient to discuss Government amendments Nos. 114 and 115.

John Denham: The amendment is a straightforward consequential change on the abolition of the NHS tribunal.
 Under piloting arrangements, representations can be made to the NHS tribunal when a doctor holding a preferential right of return applies to rejoin the health authority's medical list from personal medical services. That right of return can be overruled if the tribunal considers that the inclusion of the doctor's name would be prejudicial to the efficiency of general medical services provided in the area. The provision allows any serious problems that emerge during someone's performance of PMS to be taken into account at the stage of re-entering the GMS medical list. The Primary Care Act 1997 makes provision for conferring on the tribunal specific powers of disqualification—for example, to overrule a doctor's preferential right to return under a permanent PMS regime. 
 Clause 19 abolishes the NHS tribunal and clause 28 reconstitutes the FHSAA as its replacement. The amendments simply reassign the powers to the new body as successor to the tribunal and thus maintain comparability with the present arrangements and provisions. 
 Amendment agreed to. 
 Question proposed, That the clause, as amended, stand part of the Bill.

Philip Hammond: I should like to ask the Minister a few questions.
 Although the explanatory notes make great play of the FHSAA being reconstituted as an independent body, not a special health authority, independence is a relative term, and that interpretation depends on the belief that the Lord Chancellor is a more independent person than the Secretary of State for Health. Once members of the body have been appointed by the Lord Chancellor, they will be paid by the Secretary of State as he thinks fit. Such a situation is always dangerous—as we all know, it is difficult to be genuinely independent from the person who determines how much you are to be paid, if at all. It is fair to say that the FHSAA will be only relatively independent. 
 How will the existing FHSAA, which was presumably established as a special health authority by a statutory instrument, be wound up? The clause creates the new FHSAA as an independent body, but does not provide for the winding up of the existing FHSAA. 
 I am pleased and relieved to see that the rules governing the procedures of the FHSAA provide that appeals will be conducted through hearings, not merely written representations. That takes me back to a debate on the Care Standards Act 2000, in which we argued that when a person's livelihood is threatened, they should have the right of access to a hearing, not be limited to making representations in writing. I have to say that our argument was not accepted, but I am glad that the provision is in the Bill. 
 The Minister said, in response to an intervention by the hon. Member for Isle of Wight, that the FHSAA is essentially a pool from which panels for hearings are drawn, as is normal in such circumstances. Will it be based in London and sit in London, or will regional panels sit around the country? 
 I turn to a question that I have meant to ask the Minister on several occasions during our proceedings—indeed, I have stood up in order to do so, then forgotten what I intended to ask. In order for the Committee to conceptualise the volume of business with which the FHSAA is likely to deal, will he give us a flavour of the anticipated number of refusals? In other words, in how many cases is there likely to be at least the possibility of an appeal to the FHSAA? If there will be only a couple of dozen cases a year, sitting in London as a single panel would be acceptable, but if there will be dozens or hundreds arising in each health authority district, a regional panel arrangement would be more efficient and economic. 
 Perhaps the Minister can also shed some light on the peculiar terminology in paragraph 4(b) of proposed new schedule 9A to the 1977 Act, which states that the president 
may be removed from office by the Lord Chancellor on grounds of incapacity or misbehaviour. 
We see all sorts of words in legislation, but ``misbehaviour'' is not one that I am familiar with in the context of health legislation. I wonder what ``misbehaviour'' entails? It conjures up images of the schoolroom. Will he explain why that particular word has been used and what sort of behaviour it is intended to encompass? 
 During the stand part debate, will the Minister throw a little more light on the overall size of the body? In response to the previous debate, he referred to the FHSAA as a pool. That was intended to reassure the hon. Member for Isle of Wight about lay representation, but it could have the opposite effect. If it were to have 50 members, then the fact that only one medical practitioner provides general medical services will give rise to the opposite concern. I accept that the Minister will not want to be specific, but will he give us an idea of the scale that he has in mind? 
 Finally, could the Minister satisfy my curiosity about the apparent over-representation in the present constitution of the authority of ophthalmology? What is the distinction between medical practitioners providing general ophthalmic surgeons and ophthalmic opticians providing general ophthalmic surgeons? I had not appreciated that substantial numbers of both provide general ophthalmic services. It means that there are two optical people, one dentist, one medic and one pharmaceutical person in the proposed constitution of the authority. For my enhanced knowledge and future benefit, will he explain how that works?

Peter Brand: The clause is thin and inadequate, and it has become more confusing now that we have heard from the Minister that the authority is not to be set up under the Bill, but plugs into an existing set of regulations relating to tribunal services.
 I shall echo the comments made by the hon. Member for Runnymede and Weybridge. We have medical practitioners providing general ophthalmic services because they are on a list. In fact, they are representative of local medical committees, which is a category that is entitled to join the list. However, in the modern world, someone providing services under a supplementary list should also be represented. I am unhappy that, despite the throwaway line from the Minister, this is only going to be a pool. What is the authority going to do? Will it make policy? Will it comment on the regulations, which he will promulgate, under which its judgments must be made? The Medical Practices Committee had quite an active role in some of the functions to be taken over, as does the body that will be abolished and reconstituted. 
 I would be happier if the Government decided not to include the clause, as we shall clearly have to return to it. I would have thought that primary legislation would have to specify that the appeals authority be governed by the tribunal regulations. There should be some flavour of the total numbers. Will only members of the authority be able to sit on panels convened by it? Will it have strategic powers, or will it merely service mini-appeal panels around the country? The Minister has left himself a big job in the way of revision, and it is sad that we will not be able to see the direction in which he is going on the appeal authority until the Bill is considered on Report. 
 Many of the issues that we have discussed at the past few sittings depend on a fair, open and accessible appeals authority. Judging from the Bill, the authority does not look very open, so it is difficult to assess whether it will be fair to either the practitioner or the community.

John Denham: Let me attempt to address some of the issues. We have so far spoken to only a small amendment, so we should outline our proposals for the operation of the reconstituted FHSAA. I will start with our reasons for the proposed reconstitution.
 We announced in July that we wanted an appeal right to the FHSAA for contractors who had been removed from health authority lists. As a special health authority with members appointed by the Secretary of State, we feared that the existing FHSAA would not be considered sufficiently independent to satisfy the requirements of the European convention on human rights. I do not believe that there has ever been evidence under this or previous Govts of Secretaries of State interfering with the FHSAA, but the legal protection that may now be required under the convention is not provided for. 
 In giving the body new status, we are taking existing provision further. The Bill makes it clear that we want to reconstitute the appeals authority, with members appointed by the Lord Chancellor. That is the first distinct difference from the present FHSAA, the members of which are appointed by the Secretary of State. 
 The new body will continue to hear the appeals delegated to it by the Secretary of State, which include disciplinary committee decisions if a GP is in breach of terms of service as a result of, say, failing to provide out-of-hours services. Also included would be appeals against decisions of health authorities on fees, and appeals relating to the provision of pharmaceutical services. Those are the existing functions of the FHSAA that will transfer to the reconstituted body. 
 The second function is in relation to determining appeals that arise from the clauses that we have debated today. Examples would include failure to admit a contractor or a provider of PMS or PDS, failure to remove a person from a health authority list, and the refusal of a health authority to review a contingent removal decision. An additional important function is the ability to determine that a practitioner who has been removed from one health authority list should be removed from all health authority lists or prevented from joining other health authorities. Practitioners will have a right of appeal against FHSAA decisions, but only to the High Court and only on a point of law. That is consistent with other appeal bodies that come under the supervision of the Council on Tribunals. 
 I may previously have inadvertently misled the Committee. The Bill is the mechanism by which the body that we are considering will be established. The Council on Tribunals oversees the workings of tribunals; we intend that the appeals authority will be included. The Council on Tribunals issues an annual report on the work of the tribunals with which it is concerned.

Philip Hammond: Will that be a statutory or an extra-statutory role?

John Denham: I offered earlier to write to the hon. Gentleman to clarify the exact relationship. I do not want to mislead the Committee; a significant statement about the independence of the relevant body is involved.
 Our amendments will set out proposals for the constitution of the appeals authority, including provisions for the appointment of members and the number of members needed to ensure fairness and efficiency. Those matters will be determined by the Lord Chancellor in consultation with the Secretary of State. The intention is that the authority should be headed by a legally qualified president and deputy presidents and that the panel of members should include representatives of the contractor professions, lay members and legal lay members. The exact number of lay members is a matter for discussion. It seems reasonable to expect a similar number to the number of professional members identified in the current draft. We shall want to return to that question. It is a fair point that with 100 lay members the body would look very different. A similar order of magnitude is a reasonable way to describe our current intentions.

Peter Brand: May we have an assurance that total numbers will be set out in primary legislation? It appears at present that although we might specify certain matters in the Bill, much that could affect the workings of the clause is being left to the Lord Chancellor, of whose thinking we have no inkling.

John Denham: We must be careful about making such a promise at the moment. We want at this stage to avoid doing anything that will constrain the proper discretion of the Lord Chancellor, so as to compromise the independence that we want to bring about. In addition, it is probably undesirable to put exact numbers of members in the Bill, in case circumstances should change in future. It should be possible to provide the hon. Gentleman by Report with a clearer idea of the overall shape of the body as we expect it to be established initially.

Philip Hammond: The Minister really must not plead the need to protect the proper independence of the Lord Chancellor in making the relevant decision as a reason for not answering, when the Bill itself states that the number specified by the Lord Chancellor shall have the consent of the Secretary of State. Clearly the Secretary of State, on whose behalf the Minister is speaking to the Committee, has a power of veto.

John Denham: One issue that we must consider between now and Report is whether the wording of paragraph 2 of the proposed new schedule is appropriate.

Philip Hammond: This may be a point of order, Mr. Maxton. I take it that I am right. The Minister sighs, but we, the humble members of the Committee, can consider only the Bill that the Government have presented. We cannot be expected to second-guess what the Government might be thinking about doing by Report. The whole point of the Committee is to scrutinise the Bill. It is disingenuous of the Government to have in mind a raft of amendments that they do not table in Committee, and to wait until the effective end of scrutiny and table them on Report.
Mr. Denham rose—

Peter Brand: On a point of order, Mr. Maxton. If the clause is not agreed, can the Minister table an alternative clause later in the Committee's proceedings?

John Maxton: Of course he can.

John Denham: Having indicated last week that the Government would need to table amendments on Report, it might help the Committee to know how we want the authority to operate. It will be for the Lord Chancellor to determine the qualifications and experience that members of the FHSAA must possess. The constitution of panels to hear cases will be at the discretion of the president, as will some of the operational matters that have been raised.
 I was asked about the location of the authority. I would prefer that the staff remain in Harrogate; we would not want to lose the expertise of those staff who now work for the FHSAA. It will be for the authority itself to determine whether there should be regional panels, and it would depend on the case load. It is difficult to put an exact figure on the number of cases that might be brought forward, but we expect the president's job to be part-time father than full-time. 
 As for the other bodies that will come under the supervision of the Council on Tribunals, the Lord Chancellor will need to lay down certain rules on the functions of the appeals authority. Amendments will be tabled to make provision for that. We shall need to table amendments to require the appeals authority to prepare an annual report, and to allow regulations to be made on the procedures to be followed on the receipt of an appeal. Those amendments will make a significant number of changes, and I regret that the clause is not as fully developed as I would like. None the less, I believe that it is sufficiently correct for me to move that it stand part.

Philip Hammond: In view of what the Minister said, the Department of Health might like to think next time it presents a Bill about making use of the pre-legislative scrutiny arrangements introduced by the Government. It seems that health Bills need many Government amendments; perhaps it happens with other Bills, too.
 The Minister has not replied to several specific questions. I remind him of them. How and by what method will the special health authority be disbanded, if that is the case? What are we to understand by the term ``misbehaviour'' in paragraph 4(b) of proposed new schedule 9A? Will the Minister explain about medical practitioners and ophthalmic opticians providing general ophthalmic services? I certainly do not understand that matter, and I would appreciate an explanation. 
 I have not told the Minister—although I have told his colleague the Minister of State, Department of Health, the hon. Member for Barrow and Furness (Mr. Hutton)—how pleased I am that he has decided to err on the side of caution in ensuring that the statement made by the Secretary of State that the Bill is compliant with the Human Rights Act 1998 is correct. 
 In my constituency, there is a card-carrying member of the Labour party, who happens to be a professor of law. There are not many card-carrying members of the Labour party in my constituency, but he is a very nice chap, and he is about to publish a book that covers the Human Rights Act. One part of the book, which will be of great interest to Ministers, contains the opinion that if a Minister makes such statement on a Bill, the Bill becomes law and the courts subsequently find that the Act is not compliant, the Minister will be required to resign, having materially misled Parliament. Perhaps the Minister will pass on that snippet of information to the Secretary of State. I am sure that my constituent, being a card-carrying member of the Labour party, will ensure that Government Members receive copies of the book when it is published. I am delighted that the Minister has decided to err on the side of caution.

John Denham: I am always interested in the opinions of counsel who none the less always end up losing in court.
 Medical practitioners who provide general optical services are not ophthalmic opticians, but in many cases they are not engaged in providing general medical services. If they are not specifically mentioned, they will not be represented. 
 The FHSAA will be wound up by order under existing legislation. 
 The reason for using the word ``misbehaviour'' is that that term is used in getting rid of judges. 
 Question put and agreed to. 
 Clause 28, as amended, ordered to stand part of the Bill. 
 Further consideration adjourned.—[Mr. Jamieson.] 
Adjourned accordingly at twenty-six minutes past Six o'clock till Tuesday 30 January at half-past Ten o'clock.